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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. REFERENCES 1. World Health Organization. ICD-10 Classification of mental and behavioral disorders. Oxford University Press, 1992: F4: 151-161. 2. Fallon BA, Qureshi AI, Laje G, Klein B. Hypochondriasis and its relationship to obsessive compulsive disorder Psychiatr Clin North Am. 2000 Sep;23(3):605-16. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington, DC, 2000. 4. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and DiagnosticGuidelines.http://www.who.int/classifications /icd/en/bluebook.pdf (Accessed on April 25, 2011). 5. Creed F, Barsky A. A systematic review of the epidemiology of somatisation disorder and hypochondriasis. J Psychosom Res 2004; 56:391. 6. Ford CV. Dimensions of somatization and hypochondriasis. Neurol Clin. 1995 May;13(2):241-53 7. Adams WG. Rabies. In Nelson Text Book of Pediatrics 17th Ed. Beherman RE, Kliegman RM, Jenson HB. Editors. Saunders 2004: p 1101 -1104. 8. Wurtz R. Psychiatric diseases presenting as infectious diseases. Clin Infect Dis. 1998 Apr;26(4):924-32. 9. Fraser WI, Leudar I, Gray J, Campbell I. Psychiatric and behaviour disturbance in mental handicap. J Ment Defic Res. 1986 Mar;30 ( Pt 1):49-57. 10. Garlipp P., Godecke-Koch T., Dietrich D.E., Haltenhof H. (2004). Lycanthropypsychopathological and psychodynamical aspects. Acta Psychiatrica Scandinavica, 109(1):19-22. 11. Fishbain DA, Barsky S , Myron Goldberg M. Monosymptomatic Hypochondriacal Psychosis: Belief of Contracting Rabies. The International Journal of Psychiatry in Medicine.1992; 22(1):3-9. 13