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| “Psychogenic vomiting” – A potential transdiagnostic psychological construct: Inferences from case series |
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Anirban Ray1, Ayoleena Roy2, Aniruddha Basu3, Sukanto Sarkar4
1 Professor, Jalpaiguri Govt. Medical College, Kalyani, West Bengal, India
2 Clinical Psychologist, Department of Psychiatry, AIIMS, Kalyani, West Bengal, India
3 Associate Professor, Department of Psychiatry, AIIMS, Kalyani, West Bengal, India
4 Additional Professor and Head, Department of Psychiatry, AIIMS, Kalyani, West Bengal, India
Click here for correspondence address and email
| Date of Submission | 14-Aug-2022 |
| Date of Acceptance | 09-Jan-2023 |
| Date of Web Publication | 28-Feb-2023 |
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Psychogenic vomiting is often diagnosed in the absence of medical, psychiatric, or other conditions. Although functional gastrointestinal disorders are now an established entity, still psychogenic vomiting has its place as a temporary diagnosis till a more definitive diagnosis emerges, particularly during the developmental period. The usefulness of psychogenic vomiting is illustrated by four interrelated pediatric cases as a forerunner of formed psychopathology or as an epiphenomenon of significant psychosocial issues. Hence, psychogenic vomiting can be advocated to have a more prominent place in nosology in the coming years.
Keywords: Functional gastrointestinal disorders, psychogenic vomiting, psychosocial factors
How to cite this URL:
Ray A, Roy A, Basu A, Sarkar S. “Psychogenic vomiting” – A potential transdiagnostic psychological construct: Inferences from case series. Arch Ment Health [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.amhonline.org/preprintarticle.asp?id=370754 |
| Introduction | |  |
Leibovich defined psychogenic vomiting to be the “consequence of an emotional upset or a more profound psychic disturbance and only after physical, biochemical, radiologic, and endoscopic examinations are negative.”[1] Psychogenic vomiting has been described since the 1940s and has mostly traced the history of the development of the field of psychology like initially psychodynamic thereafter, behavioral followed by cognitive behavioral paradigm.[2] The absence of medical or the so-called organic basis has been a fundamental premise of the development of the concept of psychogenic vomiting.[3] With the advent of the concept of functional vomiting and cyclical vomiting, it has often been subsumed under such categories. Cyclical vomiting or episodic vomiting is often akin to abdominal migraine.[4] Functional vomiting is defined as per Rome's classification as vomiting which lacks cyclical nature, known medical basis, and is not related to cannabis use, rumination, eating disorder, or other psychiatric disorder.[5] However, there remains a small subgroup that cannot be categorized as such and for whom the concept of psychogenic vomiting is still useful, as we shall see in the four interrelated cases.
| Case Series | | |
Case 1
Child A, an 8-year-old boy studying in 3rd standard belonging to a Hindu nuclear family of urban background with normal developmental and birth history, was referred for repeated nonbilious, projectile vomiting with abdominal pain and constipation. Previous medical records and hospitalizations were noncontributory. There was one episode of disciplinary action in school, which led to a negative attitude and unpleasantness toward school. His academic performance in school is average in nature, and for this, he was subjected to high parental expectations and pressure related to better performance in academics. His father was a dominating and inflexible person who had sought treatment for anxiety symptoms in the past. Family assessment revealed unequal distribution in terms of decision-making in the family, where the father is acting as the authority figure. Temperamentally, the child was seen to get tensed easily, hesitant with a few numbers of peers, and has a high sensitivity to criticism, suggesting slow to warm up. On mental status examination (MSE), the child was well-kempt and tidy and observed to be shy and anxious in nature with mostly preoccupied about his performance.
A detailed evaluation revealed a temporal association between vomiting, study, and school timings. In the three-wish test, the child-mentioned his underlying need for excelling in academics as one of his wishes to meet parental expectations. Before considering it from the psychological aspect, the child was evaluated thoroughly by the department of pediatrics. As all the organic cause was ruled out, he was referred to the department of psychiatry for evaluation.
Detailed clinical interview and psychological assessment such as sentence completion and draw a family test revealed his anxiety related to his performance in school and strained relationship with his parents because of their dominance. He was managed mostly in the cognitive-behavioral paradigm. No psychotropic was provided to the child, and the management was done nonpharmacologically. The initial session focused on rapport establishment, and later on, different coping strategies and problem skills were discussed. Within seven to eight sessions, the child started improving with these techniques along with proper parental management training, which helped modifying their communication and interaction patterns with the child. He was followed up initially once in a week and later on fortnightly. The child was evaluated based on the frequency of vomiting and attendance in school per week with intensity and frequency of reporting fear while attending school or during studying per week. He is maintaining well with the psychotherapy sessions and booster sessions are continuing.
Case 2
Child B, a 6-year-old girl child studying in 1st standard belonging to middle socioeconomic status a Hindu nuclear family of the urban background, was referred with the chief complaints of repeated vomiting after ruling out all medical causes of vomiting. Her birth and developmental history were uneventful. The child was temperamentally restless and stubborn, indicating a difficult temperament as well as showed defiance toward her parents, especially her mother, who would subject her to authoritarian parenting. Initially, she was afraid of people with white hairs and insects, which generalized to food substances mostly white in color like white rice. White food substances like rice, due to its physical properties like color became the conditioned stimulus in this case. She would have nonbilious, profuse, projectile vomiting without nausea after having rice initially, which later generalized to vomiting in relation to any kind of food. She would keep the food in the vestibule of her mouth and resist all attempts of her mother to force her to swallow the food. She would take punitive measures in response to her resistance. On MSE, the child was found to be restless, mood being cheerful but she was preoccupied with the thought of getting scolding from her mother. In this case, basically, traits are of phobic anxiety disorders, although the criteria meeting would be difficult. Food phobia could be an appropriate name also. However clearly, the presentation is of psychogenic vomiting.
Detailed behavioral analysis using the antecedent-behaviors and consequences (ABC) charting revealed that she would get worried before food intake about vomiting out the ingested food, and consequently, she was refusing food most of the time. Her vomiting not only temporally correlated with her apprehension but also a mode of showing anger toward her mother because of her authoritarian parenting style. The ABC charting also reflected her attention-seeking behavior as well as the way avoidance technique was used by her mother to reduce her vomiting. This avoidance technique, in turn, is acting as the negative reinforcement in this case.
On parental behavioral management, the avoidance techniques were addressed-rather than refusing the food due to her worry about vomiting out the food, it was planned to have it in minimal amounts and to increase the amount of food gradually. Moreover, her intake of a minimal amount of food was paired with social reinforcers to increase her behavior. Breathing exercises training was incorporated to deal with her worry while having the food. After the 3 months of management, her parents reported about 60% improvement in vomiting in terms of its frequency of occurrence.
Case 3
Child C, a 4-year-old boy, belonging to urban background Hindu nuclear family, with normal speech, and other developmental milestones. Temperamentally, the child was cheerful and active in nature. He was referred with the chief complaints of repeated profuse vomiting with retching and nausea whenever he notices some specific food items such as brinjal and any kind of vegetable curry. As there was no contributory organic cause in this case, the child was referred to the department of psychiatry for further evaluation.
The detailed evaluation revealed that even the sight of some particular food items would evoke vomiting, as without sight of those food items, the child could take food as usual. Even mixing food items like any vegetable curry with their hands would make them feel nauseated. This discomfort is also present when his feet would get dirty or when he notices dirt on anyone's face. Moreover, to reduce his vomiting and unpleasantness, his mother would send him to the room whenever they had meals and would not give him those items that would evoke vomiting. Thus, these avoidance techniques would act as negative reinforcement for the child.
Case 3 has some features of obsessions alongwith some sensory issues. Although these features have not met the criteria of obsessive– compulsive disorder as per nosology, still it can be considered as obsessive equivalent that presented with psychogenic vomiting.
Like child B, in this case, also his mother was instructed to expose him to the food items gradually following a proper hierarchy, starting with the picture of the food, then only a glance at that food from a distance, from a close proximity, observing others to have them, giving him to have it instead of using avoidance techniques. The hierarchy was prepared based on the responses of the child during the session as well as the observation of his mother in different contexts. With the exposure of the food items, retching behavior was constant on every exposure, but he would not vomit on each occasion. His frequency of vomiting decreased gradually, and there was an improvement in his behavior.
Case 4
A 10-year-old girl with short stature and a stocky build belonging to middle socioeconomic status Hindu nuclear family from urban background presented with 1-year duration of the recurrent projectile, nonbilious, and voluminous vomiting. The girl had normal birth history and developmental milestones without significant medical history. Temperamentally, the child was stubborn with minimal peer engagement. However, she was sincere and reasonably well in her studies and no significant hyperactivity or inattention was noted. One year before the presentation, she started to vomit out food within a short time of her food intake. She had a ruminative style of thinking and was broody in her approach, but initially, no prominent mood symptoms were found. History neither suggestive of any hallucinatory experiences or first-rank symptoms nor any clear-cut obsessive thoughts, ideas, or images. Since no underlying cause was elicited, the patient was considered to be suffering from psychogenic vomiting and regular sessions were taken to understand the phenomenology and associated psychosocial issues.
She continued to vomit intermittently in the same pattern and continued following up. After 2 years of management and successive MSEs, a different perspective emerged that revealed that the child had a negative body image. Despite her good academic performance in school, she wanted to perform better to compensate for her looks. Her beliefs could be phenomenologically understood as an overvalued idea if not delusion. Her thoughts would consist of mainly worry regarding body image and peer relations. She considered that the peer avoidance was due to her poor looks. After 5–6 sessions focusing on psychoeducation and efforts to address her body-image problems, it became evident that her metacognition is still developing. She had a comorbid persistent and pervasive low mood which can be attributed as childhood depression and hence she was managed predominantly with selective serotonin reuptake inhibitor.
Case 4 could have a comorbid diagnosis of bulimia nervosa. In fact, we would say it was presented as psychogenic vomiting at age 10, which is not really a valid diagnosis as per nosology. It was basically a transdiagnostic condition of interest that needed exploration. At that age, she was not in a developmentally appropriate stage to meet the thought criteria of a bulimia nervosa.
Long-term psychotherapeutic support was provided in the form of a trusted therapeutic relationship. Nonjudgmental stance and acceptance held the key here rather than a structured cognitive behavioral therapy module for bulimia. The child in her mid-adolescence stage seemed to have outgrown her emotional turmoil of adolescence and went into the phase of identity acceptance. She had been performing the daily chores independently and her academic performance in school was average. She learned the culturally acceptable style of interaction in her peer group, leading to the normalization of her peer relationship.
| Discussion | | |
Recurrent vomiting, especially in children, is a difficult problem to manage. First, it needs to be ensured that all red flags are addressed in our case series, none of the patients had predominant or acute abdominal pain, hematemesis, bilious vomiting, headache, or signs and symptoms of raised intracranial tension, or any other medical or surgical causes [Figure 1].[4] Often, it is difficult to rule out rare metabolic conditions, but careful history-taking and a battery of relevant investigations often serve the purpose. The symptoms cannot be attributed to another medical condition, psychiatric disorders, including eating disorders, and chronic cannabis use to diagnose a “functional” gastrointestinal disorder.[6] This exercise is often more difficult than just stated, particularly in children where the developmental perspective works as a greater masquerader, as seen in the above case series, particularly case 4. In this case series, the first child A, 8 years old is in the age of onset of phobic anxiety disorder, with behavioral inhibited temperament, and authoritarian and coercive parenting, the performance anxiety is often manifested as vomiting. In the second child B, a 6-year-old girl with prominent stubbornness and defiance as temperamental traits, vomiting may be thought to be precipitated by anxiety and maintained by negative attention-seeking behaviors. The third child C, food fads, obsessionally and sensory issues may manifest as vomiting. While in child D, psychogenic vomiting was a temporary diagnosis that finally gave way to body-image disturbances. For a summary of the case series, [Figure 1] can be referred.
One may argue about the usefulness of psychogenic vomiting vis-à-vis functional gastrointestinal disorder. A diagnosis of psychogenic vomiting keeps the avenue open for future more definite diagnosis, as we see in the case of child D. We propose that “psychogenic vomiting” can be a transdiagnostic construct similar to catatonia, school refusal or a prodromal condition[7],[8] or attenuated psychosis syndrome (APS).[9] Though catatonia and APS have found their place in newer nosological systems such as Diagnostic and Statistical Manual of Mental Disorders-5 and International Classification of Diseases-11 but psychogenic vomiting has lost its way.[9],[10] Hence, in this era of the gut-brain axis, these four cases advocate a firm place for psychogenic vomiting, which is not only a mode of communicating distress but also a more serious condition – A harbinger of future psychopathology or epiphenomena of underlying conditions.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Leibovich MA. Psychogenic vomiting. Psychotherapeutic considerations. Psychother Psychosom 1973;22:263-8.  |
| 2. | Van Oudenhove L, Vandenberghe J, Demyttenaere K, Tack J. Psychosocial factors, psychiatric illness and functional gastrointestinal disorders: A historical perspective. Digestion 2010;82:201-10. |
| 3. | Hill OW. Psychogenic vomiting. Gut 1968;9:348-52. |
| 4. | Lee LY, Abbott L, Mahlangu B, Moodie SJ, Anderson S. The management of cyclic vomiting syndrome: A systematic review. Eur J Gastroenterol Hepatol 2012;24:1001-6. |
| 5. | Aziz I, Palsson OS, Whitehead WE, Sperber AD, Simrén M, Törnblom H. Epidemiology, clinical characteristics, and associations for Rome IV functional nausea and vomiting disorders in adults. Clin Gastroenterol Hepatol 2019;17:878-86. |
| 6. | Boronat AC, Ferreira-Maia AP, Matijasevich A, Wang YP. Epidemiology of functional gastrointestinal disorders in children and adolescents: A systematic review. World J Gastroenterol 2017;23:3915-27.5. |
| 7. | Kearney CA, Lemos A, Silverman J. The functional assessment of school refusal behavior. Behav Anal Today 2004;5:275. |
| 8. | Fink M, Shorter E, Taylor MA. Catatonia is not schizophrenia: Kraepelin's error and the need to recognize catatonia as an independent syndrome in medical nomenclature. Schizophr Bull 2010;36:314-20. |
| 9. | American Psychiatric Association D, American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Association; 2013. |
| 10. | |
Correspondence Address:
Aniruddha Basu,
Department of Psychiatry, AIIMS, Kalyani, West Bengal
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_126_22
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