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Journal of Case Reports in Practice (JCRP) 2013; 1: 11-13
CASE REPORT
Rabies or a psychiatric disorder? A rare case report
REZA BIDAKI1, SEYYED MOHAMMAD MAHDY MIRHOSSEINI2, FATEMEH ARAB BANI ASAD3
1
Assistant professor of Psychiatry, Rafsanjan university of medical sciences, Rafsanjan, Iran, 2Medical student. Isfahan
university of medical sciences, Isfahan, Iran. 3Medical student. Rafsanjan university of medical sciences, Rafsanjan, Iran
Abstract
The rabies virus entered the body, the virus moves towards the brain along the nerves. Manifestations of rabies
appear after 10 to 50 days from entrance of virus to the body. The first symptoms of the disease in humans
include: pain at the bite site, a general feeling of illness, depression, headache, nausea, and vomiting. As the virus
begins to proliferation and multiply in the spinal cord or brain, neurological symptoms would appear, including
Anxiety, confusion, excessive saliva production, hallucinations, high level of excitement, insomnia, restlessness,
paralysis of lower legs, voice box spasms and problems swallowing due to painful throat.
Pseudorabies where the person after an animal bite behaves as if he is afflicted with rabies, is well introduced in
literature and it is one of differential diagnoses of rabies. A 27 year-old, single male with hypochondriasis, a
overvalued idea that he had contracted rabies. The patient failed to respond to multiple somatic therapies and
twice made a serious suicide attempt. The patient believed in that he is rabid and attack to persons for biting
them and bitted himself.
The psychodynamics of the present case is various. Our patient had a painful experience, which was traumatizing
to his ego, and this precipitated the conversion symptoms and finally the diagnosis was hypochondriasis plus
conversion disorder.
Key words: Rabies, Conversion disorder, Hypochondriasis
INTRODUCTION
The term conversion implies that the unpleasant
affect caused by the conflicts and challenges that
the individual cannot solve is transformed into the
symptoms(1).4
Hypochondriasis
was well demonstrated
by
Kellner , which showed that patients with high levels
of diseases fear tended to be more anxious or phobic,
whereas patients with high levels of illness
conviction tended to have more severe somatic
complaint. Hypochondriasis is a heterogeneous and
chronic disease which occur almost equal in men and
women. The data
indicate a closer relationship
between hypochondriasis
and
somatization
disorder than
between hypochondriasis
and
obsessive-compulsive disorder(OCD) (2-5).
Corresponding author:
Rafsanjan, Moradi Hospital, Psychiatry Service
Tel : +983915230081
Fax : +983915230086
Email address: [email protected]
Some of
the
patients, communicate their
psychosocial
distress in the form of physical
symptoms are called somatizers. They prefer to
over use medical services(6).
From the point where the rabies virus entered the
body, the virus moves towards the brain along the
nerves. Manifestations of rabies appear after 10 to 50
days from entrance of virus to the body. The first
symptoms of the disease in humans include: pain at
the bite site, a general feeling of illness, depression,
headache, nausea, and vomiting. As the virus begins
to proliferation and multiply in the spinal cord or
brain, neuropsychological symptoms would appear,
including Anxiety, confusion, excessive saliva
production, hallucinations, high level of excitement,
insomnia, restlessness, paralysis of lower legs, voice
box spasms and problems swallowing due to painful
throat.
Pseudorabies where the person after an animal bite
behaves as if he is afflicted with rabies, is well
introduced in literature and it is one of differential
diagnoses of rabies(7).
Although
various psychiatric disorders
have
somatic manifestations, some indicate fears or
delusions of infection. When a patient with a past
Reza Bidaki et al.
psychiatric history referred to an infectious disease
physician, the physician may find the problem
confusing, wondering and ultimately frustrating till
the psychiatric cause for disease is identified (8).
Also a study reported on the relationship between
behavioral and psychiatric perceptions of mentally
handicapped subjects. A Standardized Psychiatric
interview schedule was found to characterize
psychiatric problems in the mentally handicapped
along eight dimensions: depression, neurasthenia,
psychoticism,
phobias,
histrionic
elation,
hypochondria, mental retardation and medication
effects. Clinical features were not expressed in
behavior disturbances, nor were they related to age,
sex
or
hospitalization.
However,
the
communicativeness of an interviewee was found to
limit the detection of depression (9).
CASE PRESENTATION
The authors describe a 27 year-old, rural single male,
low
socio-economic with hypochondriasis , a
overvalued idea that he had contracted rabies with
pseudoseizure attacks (Conversion disorder /Motor
type). His education was very low (he did not finish
the elementary school). The patient failed to respond
to multi model medical therapies and twice
made a serious suicide attempt. There was history of
being bitten by a dog 8 years ago and the dog not
died at that time (It wasn't rabbied ).A Physician
told him that illness is very dangerous and
survival is very low. At this time, he was worried
with pain only. A provisional diagnosis of rabies
was made and the man was given supportive
treatment. His father died when he was 9 year-old.
Sleep disturbance was started at this time. His
grand father died 17 years ago and he was
depressed. These are confirmed a pathological greif
for this patient. There is no information about his
depression treatment and he said that he did not any
treatment for his depression mood. Relationship with
other family memberships is not favorable. His
brother has the biopolar disorder. He had admitted in
psychiatry service three times and diagnoses were
major depressive disorder (MDD), conversion
disorder and bipolar disorder.He believed in that
he is rabid and attack to persons to bit them and
bitted himself.He was talkative without pressure of
speech, worried about disease. Circumstantiality was
apparent. He was sensitive to rejection and his
attachment to theraputic system was considerable. He
had attention seeking, sick role and illness
behavior was obvious. He exposed his hands
continuously and believed that his hands are
necrotized
because of infection. Physical
examinations and lab tests were normal. Serological
tests for anti -rabies antibodies were negative.
Journal of Case Reports in Practice (JCRP) 2013; 1: 11-13
Irritable and Euphoric mood were detected and
positive familial history for Bipolar disorder was
positive. Therefore
we
suggested " Bipolar
disorder/ Mixed type. “Malingering” was been ruled
out because he did not want to receive any gain from
his family. Also we did mind “Facticious disorder”
because of his dependency
to the hospital
environment ( But psychiatric signs were more
extend of this diagnosis. “Delusional disorder ” was
suggested because of belief about be rabies but his
belife was loose some times ( Delusion wasn't
fixed) and this is the reason for rule out delusional
disorder for this patient. So a retrospective diagnosis
of Hypochondriasis comorbid
with conversion
disorder were suggested .
DISCUSSION
Our case have many factors for somatoform
disorder. He have cognitive
error
and
misperception because intellectual borderline IQ
and low academic level. He was been bitten by a
dog, then a physician frightened him because
tetanus. Immunoglobulin was delayed for
prescription to him. He had fear for have
tetanus and asked some persons about this illness.
Finally, this idea was formed and extended
insidiously. He had no secondary gain , therefore
malingering isn't suggested. He was dependent in
hospital environment because fear of progression
of illness and death.
Conversion disorder is closely associated with
traumatic and stressful events, or impaired
relationships.
Occupational and social disability, absenteeism, poor
productivity and unemployment are severe. A
person with hypochondriasis has a poor quality of
life, are socially isolated, depressed and at a high rate
of committing suicide .
It is important to discern whether physicians have
any element of conversion , because this may have
some impact on their practice and specifically, their
perception of a patient's physical defects.
Diagnosis and differential diagnosis are discussed
with regard to other somatoform disorders such as
body dysmorphic disorder and somatization
disorder. But there are not other criteria for
other somatoform disorder. He is worried from
hands appearance, but it is because fear of
tetanus.
A case report on a patient with somatoform
disorders is presented and the psychopathological
views are compared to other reports in the other
articles . The psychodynamics of the present case is
various. Our patient had a painful experience, which
was traumatizing to his ego, and this precipitated the
conversion symptoms. Development of the symptoms
12
Rabies or a psychiatric disorder?; A Rare Case Report
helped to reduce the psychological distress and
anxiety resulting from the conflict (primary gain).
After all we could suggest “Licantropia” as a
differential diagnosis for this patient. In Licantropia,
patient believed that he has
changed or
transformed to a wolf(10). Our case believed
that he is rabbied. He didn't say "I am a wolf or
dog ".
Fishbain
described
a
"Monosymptomatic
Hypochondriacal Psychosis" (MHP) that she had
delusional belief with rabies. The patient was nonresponder to multiple somatic therapies (11).
Although our case
had multiple somatic
complaints and antipsychotic therapy, but patient
failed for treatment. Even six session ECT didn't
change patient symptoms. One
of the most
important differential
diagnosis
is psychotic
disorders like delusional disorder. But when we
mentioned him and listened his speech we
could pleased
him that there isn't
rabies
temporary. He had attention seeking , sick role
and illness behavior. Therefore this is a over
valued idea and isn't a delusion. Therefore,
Psychotic disorder is ruled out.
It maybe that who suggest encephalitis post
infection. But
our
case
had not
the
signs/symptoms related to rabies. He had not
saliva drooling, aerophobia, photophobia and other
common subjects. Of course during the acute
phase of illness hypomania with delusions, and
hallucinations might happen (12).
In previous literature, It pointed only to Cancer,
HIV, Multiple sclerosis and Hepatitis in definition
of hypochondriasis . But we didn't find no report
about hypochondriasis and Rabies. Therefore we
suggest that this link can add to previous list of
diseases and hypochondriasis.
CONCLUSION
We recommend that patients presenting the psycho
pathological features of conversion disorder and
hypochondriasis should be conservatively observed
and an attempt to clarify both the organic and the
psychiatric diagnosis should be made before any
invasive procedure is undertaken.
Journal of Case Reports in Practice (JCRP) 2013; 1: 11-13
AUTHOR’S CONTRIBUTIONS
RB and SMMM revised the manuscript. RB made
the diagnosis and helped to draft the manuscript. RB,
SMMM and FABA searched and collected the data.
RB and SMMM helped to edit the manuscript. All
authors participated in data analysis, read and
approved the final manuscript.
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