Appendicitis in a patient with psychiatric problem and drug withdrawal symptoms.

Physical disorders can be seen in psychiatric patients. In addition, a delayed diagnosis can cause a serious complication of the physical disorder among such patients. In this report, a case of appendicitis in a psychiatric case with drug withdrawal symptoms was reported.

Sometimes, it is hard to discriminate between real physical disorders and somatoform disorders (1). Somatoform disorder might mimic authentic physical illness and can result in misapplied treatment (2). Nevertheless, it should be mentioned that actual physical disorder can be seen in psychiatric patients. Kozumplik et al. noted that it was needed to concern on somatic illness in any psychiatric patients (3). However, the signs and symptoms of physical disorders among psychiatric patients are sometimes not predominant and can be mimicked by the psychiatric abnormality. This causes difficulty for diagnosis. Furthermore, a delayed diagnosis can be a serious complication of the physical disorder among the psychiatric patients. In this report, a case of appendicitis in a psychiatric case with drug withdrawal symptom was reported. The aim of this case report was to help the reader to recognize the importance of comorbidity of somatic illness in psychiatric patients which can be easily under diagnosed.

Case report

A male patient was referred to a physician in a clinic with the chief complaint of abdominal pain for 2 – 3 days. The patient's sister noted that the patient was a psychiatric patient diagnosed with depression, anxiety as well as drug addiction. The patient had just skipped using amphetamine and marijuana for 10 days before. The patient's sister also noted that the patient had no verbal communication due to intentional omitting of speaking and denying all drugs for 7 days.

Considering the patient's history, the patient also presented agitation, sleeplessness and increased appetite at that period, which matched the description of amphetamine withdrawal. The patient presented no fever, constipation or diarrhea. This case was examined by the physician in charge and he found that the patient had voluntary abdominal guarding and poor cooperation with physicians. His vital signs were within normal range. His pharynx and throat were normal. The patient was firstly suspected to be a possible case of drug withdrawal, and the abdominal pain was treated by oral and intravenous antispasmodic drugs. However, the patient had no better symptom. The patient was referred to the hospital and monitored at the emergency room for one more day. Finally by observing the generalized guarding of abdomen and considering the laboratory results (negative urinalysis, neutrophilia from complete blood count), the patient was diagnosed as a possible case of appendicitis. The surgery was set and the surgical result showed ruptured appendicitis.

Discussion

Acute appendicitis is a difficult-to-diagnose condition in many situations (4, 5). The diagnosis of acute appendicitis can be delayed in many cases and can cause problems. In this report, this case presents difficulty in diagnosis. The patient's signs and symptoms of appendicitis are not classical and fully mimicked with the underlying psychiatric signs and symptoms. Indeed, the abdominal pain can be an important presentation in the drug withdrawal case (6, 7).

It should be noted for the importance of concealing a physical diagnosis by psychiatric history or mental states (3, 8). It is estimated that about one twentieth to one tenth of the psychiatric cases might have occulted somatic disorders (9, 10). Therefore, this case report suggests that general practitioners should be aware of possible undetected physical disorders in psychiatric cases.