Psychiatric Comorbidities With Cyclical Vomiting Syndrome.

Makani, R., & Parikh, T. (2017). Psychiatric Comorbidities With Cyclic Vomiting Syndrome. American Journal of Psychiatry Residents’ Journal, 12(11), 4–6. https://doi.org/10.1176/appi.ajp-rj.2017.121102

So, I don’t really like vomit. Neither do most people, obviously. So when someone has an illness that involves vomiting, I am especially sympathetic, almost to the point of sympathetic nausea! Unfortunately, despite a well established connection between mind and gut, vomiting associated syndromes are not too heavily researched or published. This article by Makani and Parikh published in 2017, therefore, remains relatively important and is a great, succinct summary on what we know and how to help.

This paper was published in the American Journal of Psychiatrist Residents. The journal is small and exclusive to publishing papers from junior doctors and doctors-in-training. It often has interesting, relevant topics in easy-to-understand and crisp presentation.  The journal is published by the APA – the American Psychiatric Association.

The article begins by discussing cyclic vomiting syndrome. There are specific criteria called the ROME III (3) classification. And though it was first described and often occurring in children it can occur in adults as well. We do know that it is associated strongly with migraines, mitochondrial diseases and neuroendocrine disorders.

Psychiatrically, we see that anxiety and depressive disorders are observable in those experiencing this psychosomatic/neuropsychiatric disorder. In an initial study in children, more than half actually had a clinically diagnosable anxiety disorder, with panic disorder being one of the most common syndromes. Adults often have more depression and anxiety than children, as well as increased abdominal pain and gastric emptying. It appears that suppression with psychological and medication is also more effective in adults.

In terms of management, various medications are relatively effective, though not that strongly supported. It seems that Amitriptyline (TCA) is effective, both at managing the anxiety and depression that could be causing/worsening the symptoms, as well as directly modulating the vomiting through anticholinergic and serotonin.

Cognitive-Behavioural Therapy, in a multidisciplinary approach is helpful. Combining this with medication can also be helpful and might increase remission rates. Cannabis, unsurprisingly, remains controversial. Some population studies report chronic cannabis use may have an antiemetic effect, there is the considerable risk of cannabinoid hyperemesis syndrome. I have witnessed this syndrome multiple times and it is traumatic for everyone involved. Combined with the worsening of other psychiatric conditions, dependence, physical health and functional risks, I would not recommend using cannabis – at all.

The article finishes with the cost associated with the illness. Can you believe it cost $400million UDS over 2 years. I found that to be massive. It really highlights that even low prevalence disorders require active research and effective treatments.