Phobias complicating treatment of uterine carcinoma.

Phobias complicating treatment of uterine carcinoma Many people fear medical procedures and sometimes need considerable reassurance from their doctor. Only rarely are they of phobic intensity and lead to avoidance of appropriate treatment but then they constitute a major health hazard. We describe the rapid response of one patient's phobias to behaviour therapy so that urgent surgical treatment could be given. Case report A 51-year-old married woman had become phobic of hospitals and medical procedures after several periods in hospital during childhood for pneumonia, minor accidents, and a herniorrhaphy. In adulthood she avoided hospitals, having both her children at home and, on her single antenatal visit, leaving without seeing a doctor after watching another patient having a venepuncture. She also avoided dental treatment and vaccinations. There was no history of other psychiatric symptoms and no family history of phobias. For four ycars before we saw her she had had menorrhagia and had lost 19 1 kg. For nine months she had had a serosanguineous vaginal discharge, but despite advice from relatives and her family doctor she refused a gynae-cological opinion because of her phobias. Eventually she was brought, unwillingly, by her daughter to the casualty department where she was referred for a psychiatric opinion. Her main phobias were related to having an injection, the sight of blood, and being admitted to hospital for surgery. A behavioural approach to overcome these phobias was outlined to her but before starting treatment she agreed to a gynaecological consultation, which showed an enlarged uterus with a haemorrhagic discharge. Cytology confirmed the clinical diagnosis of uterine carcinoma. A rapid graded-exposure technique was employed. For the injection phobia this involved the patient initially handling needles and syringes, then, with the therapist demonstrating, injecting these into fleshy inanimate objects (oranges). Next she copied the therapist in making subcutaneous injections and finally allowed venepunctures to be performed on herself. Similar graded approaches were used for her phobias of blood and of entering the surgical ward. After six sessions of about an hour each she was able to enter hospital and undergo the necessary preoperative blood tests and pre-medication. Surgery involved a total hysterectomy and bilateral salpingo-oophorectomy, and histology showed an adenocarcinoma of the body of the uterus with superficial myometrial invasion. The ovaries, tubes, and cervix were normal. Postoperatively she refused a course of radiotherapy but was free of recurrence when last seen seven months later.