Introduction

ICD 10 defines somatoform disorder as a repeated presentation of physical symptoms that show a characteristic indulgence for repeated medical investigations even after repeated reassurances from the doctors and negative findings. Somatoform disorder includes somatisation disorder, hypochondrial disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, persistent somatoform pain disorder, other and unspecified somatoform disorder. [1] The lifetime prevalence of somatisation disorder is around 0.2%. [2] Somatoform Autonomic dysfunction is a chronic polyetiological disorder characterized by the nonspecific cardiovascular, gastrointestinal, respiratory, and neurogenital symptoms which are largely or completely under autonomic innervations or control. [3-5]

Hiccups are defines as the repeated sudden involuntary spasmodic contractions of the diaphragm and intercostals muscles which leads to glottis closure and produces a characteristic sound. Hiccups can be classified as Acute (lasts for 48 hours), persistent (lasts for more than 48 hours) and intractable (lasts for more than 1 or 2 months) [6-9].

The cause of hiccups can be idiopathic, organic and psychogenic.[10,11]  Hiccups can occur in normal healthy  individuals for a brief period which are believed to be induced by  spicy foods, carbonated drinks,  stomach distension, using alcohol etc. [12,13]  Persistent and intractable hiccups can be either organic or psychogenic. Organic causes can be gastrointestinal, cardiovascular disorders, central nervous system abnormalities, metabolic/endocrine disorder, drugs,  infections, etc. Persistent or intractable are usually benign and self-limiting but sometimes needs thorough evaluation and treatment [14]. 

Here we present a case of a 20-year-old female who presented with hiccups of psychogenic origin to our psychiatric OPD.

Case

20 years old unmarried female studied till 10^th standard hailing from rural background referred from Department of Neurology to Psychiatric OPD for evaluation. Patient has history of persistent hiccoughs from last two years. Patient was apparently alright 2 years back when she started with sudden onset of hiccups which were continuous throughout the day. Initially patient took some home-remedies to get rid of these hiccups. But these hiccups were not relieved so the patient was taken to a local physician patient who had put her on Proton pump inhibitors for few weeks but symptoms persisted, then patient was taken to a general physician, who prescribed medications of which no records were available. She continued that medication for 5-6 months but no relief in symptoms were seen. After this patient went to District hospital for the same reason and was seen by physician who prescribed medications for few months and when patient did not respond she was referred to Tertiary Care Hospital for further evaluation and management. In Tertiary care hospital, patient was seen by Gastroenterologist and all the base line investigations were advised which were within normal limits. USG abdomen was done and patient was put on metachlopromide and Baclofen. But due to persistence of symptoms, neuroimaging (Brain CT and MRI) were advised, both of which were normal. Then upper GI endoscopy and esophageal manometry were done and all the investigations were normal. Then in addition to above mentioned symptoms, the patient was prescribed Amitryptyline 25mg by Gastroenterologist for 3 months. Patients had improved for 2 days on amitriptyline and then restarted with symptoms. Despite repeated reassurance by the consulting doctors the symptoms did not resolve.  The patient was then referred to psychiatric evaluation. After detailed interviewing, the patient gave history of paternal discord in her childhood. She revealed that she was always preoccupied with those thoughts. However, her parents continued to live in harmony afterwards. There is no family history of psychiatric illness. Pre-morbidly patient has anxious personality traits. The case was discussed with consultant Psychiatrist and Clinical Psychologist and the diagnosis of “somatoform autonomic dysfunction” was made. Psychological and pharmacological treatment were started. Patient was put on Doxiepin 10 mg initially then 25 mg), Haloperidol (0.25mg bid). Psychoeducation, CBT, relaxation techniques were taught to patient. The patient was then followed weekly and patient reported improvement within 4 weeks. Patient is still follow and continuing with psychotherapy since 1 year and no episode of hiccups have been reported.

Discussion

The above case highlighted the psychosomatic cause of intractable hiccups with patient having premorbid anxious personality traits. The patient responded well to psychotropics and psychological intervention.  The patient did not respond to the conventional treatment for hiccups such as pantoprazole, domperidone, antitussive, metachlopromide, etc.[7,8] But when patient was put on tricyclic antidepressant (Doxepin) and low dose first generation antipsychotic (haloperidol) along with the psychological interventions. Very few case reports of psychogenic hiccups from India have been published.[15] This case highlighted the importance of psychological evaluation in case of persistent or intractable hiccups without organic cause and not responding to the conventional treatment methods.

Conclusion

The above case emphasized on the multidisciplinary approach while treating intractable hiccups especially when no identifiable organic cause is elicited. This would be helpful the early diagnosis and treatment of the patients.