Volume 2 Issues 9, September, 2021
Consultation Liaison Psychiatry Focus: Surgery
Referrals to psychiatry, from surgery department are not uncommon. The patients with somatisation or those with pain, that could not be localized or those with inconsistent clinical findings or those who are too anxious before surgery, do benefit from referral . Not many have explored the interface between psychiatry & surgery, which may require considerable attention, in the interest of patients.
Among patients presenting to surgery one such area of interface is in cases that are diagnosed as Trichobezoars. Bezoars are concretions in the gastrointestinal tract that increase in size by continuous accumulation of non‐absorbable food or fibers. Most bezoars in children are trichobezoars from swallowed hair. Trichobezoars typically cause abdominal pain and nausea, but can also present as an asymptomatic abdominal mass, progressing to abdominal obstruction and perforation. An unusual form of bezoar extending from the stomach to the small intestine or beyond has been described as Rapunzel syndrome.
It may be interesting to note that, Trichobezoars has close association with Tricotillomania. One in three patients with Trichotillomania swallow pulled out hairs and 40% of them develop Trichobezoars. The term Trichotillomania was coined by a French dermatologist, Francois Hallopeau, in 1889. WHO has classified Trichotillomania under habit and impulse disorders, as a condition “characterized by noticeable hair loss due to a recurrent failure to resist impulses to pull out hairs, preceded by mounting tension and followed by a sense of relief or gratification.” The diagnosis should not be made if “pre‐existing inflammation of the skin” exists or if hair pulling occurs “in response to a delusion or hallucination.” “Stereotyped movement disorder with hair‐plucking” is also specifically excluded.
The incidence of Tricotillomania has been underestimated because of secretiveness and is said to be ranging from 0.5 to 4%, more common in female gender. Causes are varied from mental retardation to co‐morbid anxiety disorders. Management involves education, addressing dermatological & surgical complications, referral to psychiatry for evaluation. At psychiatry department, after assessment, patients can be considered for Habit Reversal Training (HRT) or Cognitive Behavioural Therapy(CBT) and medications such as (SSRI) Selective Serotonin Reuptake Inhibitors or TCA (Tricyclic Anti Depressants) like clomipramine can be recommend by consultant psychiatrist.
It may be interesting to discuss individual cases with colleagues in other departments whenever there are issues which requires consultation liaison for the benefit of patients and also enhancing mutual insight about medical conditions.
JSS Medical College, Mysore
