Cases That Test Your Skills

The patient who couldn’t stop vomiting

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About 1 week before the onset of vomiting, Ms. M, who was approximately 60 lbs overweight at the onset of symptoms, received a subliminal message tape from her father pertaining to weight loss. She had listened to the tape for several days and wondered if this could have bearing on her current symptoms, since the tape represented the only change in her routine before the vomiting started.

The attending psychiatrist surmised that the escalating demands of the patient’s elderly ward created a psychological conflict between caring for her family and for her deceased friend's mother. Although the recurrent hospitalizations added to her stress, the vomiting relieved her internal conflict by rendering her unable to care for anyone, including herself.

Because physical examination findings, blood chemistries and counts, and imaging studies did not indicate a physical disorder, Ms. M's diagnosis now was psychogenic vomiting and eating disorder not otherwise specified (NOS).

How would you treat this apparent case of psychogenic vomiting? To what extent can psychological factors contribute to excessive vomiting or other gastrointestinal distress?

Dr. Wiseman’s and Dr. Dunlop’s observations

Clarke described the use of emesis to communicate psychological distress in three cases of female Asian immigrants with psychogenic vomiting.5 In each patient the onset of emesis was related to a psychological stressor, and each patient felt she gained a benefit from the chronic vomiting.

In one case, a young woman with unexplained vomiting for 3 weeks was admitted to a psychiatric hospital. During several interviews the patient revealed that she was angry with her parents because she had been relocated against her wishes and required to perform traditional domestic duties. She also felt frightened that her hostile thoughts may have caused her father to have a heart attack. A psychiatric social worker intervened with the patient and her family to address the woman’s desire to be independent. The vomiting stopped without recurrence. Continued vomiting would have changed the family’s expectations and demands, as the patient would have assumed the role of the chronically ill family member.

Of the patients with persistent psychogenic vomiting reviewed by Rosenthal, most had adjustment disorders, poor assertiveness skills, or lack of limit-setting abilities.3 In this psychological setting, vomiting can best be understood as a mechanism for decreasing anxiety and unconscious conflict. Many patients reported difficulty expressing anger, and vomiting eliminated the negative emotion.3

Further evaluaton: Another diagnosis

During her fourth hospitalization, this time at our medical center, Ms. M was treated with amitriptyline, 50 mg at bedtime, but this was discontinued when she developed orthostatic hypotension. Following 2 weeks of psychiatric inpatient treatment without improvement, Ms. M was transferred to a tertiary medical center's psychiatric service for further evaluation.

The examination revealed a mildly dehydrated, ill-appearing woman with sallow skin, hyperpigmentation of the oral mucosa, and minimal enlargement of the thyroid gland. Her blood pressure was 88/62 mm Hg, and her pulse was 112/min supine with orthostatic changes. Her weight had decreased from 195 to 144 lbs across 5 months. Serum sodium was 134 mmol/L (135-145); potassium, 5.7 mmol/L (3.5-5.5); chloride, 100 mmol/L (95-105); bicarbonate, 22 mmol/L (22-27); urea, 7 mg/dl (5-20); creatinine, 1.0 mg/dl (0.5-1.5); glucose, 117 mg/dl (70-110); and calcium, 9.6 mg/dl (8.5-10.5). Ms. M’s complete blood count was normal.

A mental status exam revealed a cooperative but anxious and ill woman without delusions or distorted body image. Ms. M did exhibit a depressed mood and diminished concentration. Her affect was sad, but she denied hopelessness or worthlessness and did not meet DSM-IV criteria for major depression or personality disorder. Results of the modified Mini Mental State Examination were normal.

As we accumulated and carefully reviewed the patient’s medical records, a constellation of signs and symptoms became apparent. These included fatigue, nausea, vomiting, hypotension, hyponatremia, hyperkalemia, weight loss, hyperpigmentation, and the report of subtle episodic psychiatric changes. The index of suspicion for a primary pathophysiologic process was raised. Hypothalamic-pituitary-adrenal axis pathology, specifically adrenal insufficiency, was considered.

An abnormal plasma cortisol level obtained at 8 AM was

A diagnosis of adrenocortical insufficiency, probably caused by autoimmune adrenalitis, was made. In addition, a thyroid function test showed TSH 22.5 IU/ml (0.13-4.6), T4 6.3 mg/dl (4.5-12.0), and T3 176 mg/dl (90-245). Consistent with primary hypothyroidism and adrenal insufficiency, Schmidt’s syndrome—an autoimmune disease of the adrenal and thyroid glands that is a subtype of Addison’s disease—was established.

Ms. M was transferred to a medical ward, where endocrinologists prescribed hydrocortisone, 30 mg in divided daily doses; fludrocortisone acetate, 0.05 mg as a single daily dose; and levothyroxine, 0.1 mg/d. She responded clinically and was discharged after 2 days. A 6-month follow-up found the patient symptom-free with body weight exceeding premorbid levels.

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