Health Care : Current Reviews

A Case of Psychogenic Vomiting

Pooja V ¹Patil University, India

Received: 15-Jan-2021 Published: 26-Feb-2021, DOI: 10.35248/2375-4273.21.9.275

Case Report

A 14 year old female, studying in class 9 in a Marathi medium school, belonging to a Christian nuclear family with three siblings and her birth order being second. Patient presented to the Emergency department with history of recurrent episodes of vomiting from one year, headache from 3 months and was admitted to medicine ward. Since relevant tests and investigations ruled out organic causes she was referred to the department of Psychiatry.

Patient was apparently alright 1 year ago, she was bullied by her classmates on regular basis over her appearance. Over time she started to feel sad and raised the concern to her mother but was not taken seriously upon. She started to have episodes of vomiting which was insidious in onset. It was not associated with nausea, frequency gradually progressive in nature. The vomiting episodes were immediately after consumption of food and water. 2-3 times per day. The vomitus was non-bile stained, non-blood stained, consisting of food particles. Not relieved on any medications. The vomiting also developed even after her eating her favorite dishes. No history of fever, pain abdomen or loose stools. Previously, she had consulted to multiple physicians admitted twice previously and relevant testes such as endoscopy done which showed low grade GERD but never showed significant improvement on any interventions. Patient also complained of headache which was insidious in onset. Throbbing type of pain, on and off. Lasting for few hours. No aggravating factors or relieving factors.

On detailed interview, the patient reported to be fine irrespective of her vomiting episodes although she had missed one year of her school and was losing weight. There was no personal distress to her. She considered herself to have been overweight and that her ideal weight is 30 kgs. She also believed since she was dark skinned and if she lost weight her friends would stop making fun of her .She also reported that she used to throw away the food at times, before the onset of the vomiting in order to lose weight. The vomiting was never self-induced.

Patient attained menarche at the age of 13 and having regular cycles. No history of any psychiatric illness in the family. Patient’s birth and development history is unremarkable. No interpersonal issues among parents or siblings. Academically, patient is good in her studies and comes within top 3 in all her exams, apart from the year which she couldn’t go to school. She did not report of being pressurized in studies or any stress in academics. She had sound sleep and also had a good appetite. On general physical examination, she was found to be moderately built but poorly nourished. No significant findings were noted in her head to toe examination and systemic examination. Her BMI was 16.6kg/m2, which is above the 3rd percentile and below the 15th percentile. Patient’s condition was managed successfully with starting the patient on Selective serotonin reuptake inhibitors and psycho-educating of the patient and the mother. On regular follow ups she is maintaining the improvement.

Discussion

The diagnostic criteria of psychogenic vomiting have not been established, there is no definite criteria. In the ICD-DCR 10, it comes under 50.5 Vomiting associated with other psychological disturbance. The patient is an adolescent female and in the literature of psychogenic vomiting female preponderance has been reported. The patient had a continuous type of vomiting pattern which was noted by earlier studies. Psychogenic vomiting was mainly noted in the younger age group in the earlier studies. In this case, the other forms of eating disorders were ruled out. Although the patient had body image distortion, she did not fulfil the criteria for anorexia nervosa. The vomiting was never self-induced nor did have any dietary restrictions, Avoidant Restrictive food intake disorder (ARFID) was also ruled out[10], patients BMI was within normal limits for age. Although patient had lost 2-3 kilograms of weight, it was not an issue with the patient or her mother. The lack of concern or the distress about the vomiting in the patient was also reported in earlier reports. Association of postprandial vomiting has been associated with depression, and mixed anxiety and depressive disorder but in our case, the patient did not have any such symptoms or complaints and hence did not fit into those criteria.

It was highlighted that academic achievement pressure often precipitates cyclic vomiting. The triggers being dear of failure, academic aspirations and going back to school.

This was higher among girls in Asian countries, facing more of these stressors. It was reported that psychogenic vomiting, being a somatic symptom, is liable to raise concern among the parents which in turn leads to increased attention and avoidance of academic pressure and absenteeism.

Management of psychogenic vomiting is known to change through the course and hence the treatment should be altered likewise. It is difficult to manage with only pharmacological intervention. The lack of time, as the case coming to a psychiatric evaluation after many other physician consultations, makes the diagnosis delayed by years causing added stress to the patient and the family which also has to be taken into an account for the management.