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give me protocol of psychogenic vomiting

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psychogenic vomiting clinical management guideline functional vomiting adults

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psychogenic vomiting treatment

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Rome IV chronic nausea vomiting syndrome diagnostic criteria psychological treatment

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https://theromefoundation.org/rome-iv/rome-iv-criteria

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Protocol for suspected psychogenic vomiting

The term psychogenic vomiting is older terminology. In current practice, consider chronic nausea and vomiting syndrome (CNVS) or functional vomiting only after medical, medication-related, eating-disorder-related, rumination, and cannabis-related causes have been assessed and excluded.

1. Initial assessment and safety

Assess:
  • Frequency, duration, timing, triggers, relation to meals and stress
  • Weight loss, dehydration, dietary intake, urine output
  • Current drugs, alcohol and cannabis use
  • Pregnancy possibility
  • Anxiety, depression, trauma, panic symptoms, emetophobia
  • Intentional vomiting, bingeing, body-image concerns, laxative/diuretic use
  • Rumination: effortless return of recently eaten food, usually without nausea/retching
Urgent referral / emergency assessment if there is hematemesis, bilious vomiting, severe abdominal pain or distension, syncope, confusion, fever, dehydration/oliguria, significant weight loss, dysphagia, neurologic symptoms, or suicidal risk.

2. Exclude organic causes before assigning a functional diagnosis

Use a targeted evaluation based on presentation:
  • Examination including hydration, weight/BMI, abdominal and neurologic examination
  • Pregnancy test when relevant
  • CBC, electrolytes including potassium, renal and liver profile, glucose, calcium, urinalysis/ketones; add lipase, thyroid testing, or other tests when clinically indicated
  • ECG if electrolyte disturbance or purging is suspected
  • Upper GI endoscopy and abdominal imaging only when indicated by alarm features or persistent unexplained symptoms
  • Gastric-emptying testing if gastroparesis is suspected
Check specifically for:
  • Medication effects, including GLP-1 receptor agonists, opioids and dopamine agonists
  • Gastrointestinal obstruction, peptic disease, gastroparesis
  • CNS, endocrine, renal and metabolic disorders
  • Pregnancy
  • Cyclic vomiting syndrome
  • Cannabinoid hyperemesis syndrome
  • Eating disorders and rumination syndrome
Vomiting can cause hypokalemia, which may produce weakness and ECG abnormalities. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, serum electrolyte evaluation.

3. Confirm a functional gut-brain disorder diagnosis

For adult CNVS, Rome IV requires all of:
  1. Bothersome nausea at least 1 day/week and/or vomiting at least 1 episode/week.
  2. No self-induced vomiting, eating disorder, regurgitation or rumination.
  3. No organic, systemic or metabolic explanation after routine assessment, including upper endoscopy when appropriate.
  4. Criteria present during the previous 3 months, with symptom onset at least 6 months earlier.
See the Rome IV criteria.
Do not label vomiting as psychogenic merely because stress is present. Stress can coexist with significant GI or medical disease.

4. Explain the diagnosis therapeutically

Use a non-stigmatizing explanation:
“The vomiting is real. Tests have not found a dangerous structural cause. The gut and brain communicate closely, and stress, anxiety and learned nausea-vomiting responses can amplify symptoms. Treatment targets both symptom control and those gut-brain pathways.”
Establish one consistent clinician, scheduled follow-up, symptom and trigger diary, and clear instructions for flare-ups. A supportive clinician-patient relationship and reassurance are central to management. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, p. 217.

5. First-line treatment

Behavioral and psychological care
  • Refer for cognitive behavioral therapy, particularly for anxiety, avoidance, emetophobia, conditioned vomiting or health anxiety.
  • Use relaxation training, diaphragmatic breathing, grounding and regular sleep routines.
  • Treat anxiety, depression, trauma-related symptoms or an eating disorder with a mental-health professional.
  • Family involvement may be helpful in adolescents or dependent adults.
  • If an eating disorder is identified, involve a multidisciplinary team: medical clinician, mental-health clinician and dietitian.
Diet and hydration
  • Small, frequent, regular meals.
  • Avoid personal triggers, large fatty meals, excess caffeine/alcohol, and strong smells if relevant.
  • Oral rehydration during episodes.
  • Correct nutritional deficiencies and electrolyte abnormalities.
  • Avoid prolonged fasting, which may perpetuate nausea and vomiting.

6. Medication strategy

Medication should be individualized by the treating clinician and used alongside behavioral treatment, not as the only intervention.
  • A short-term antiemetic may be used for symptom relief.
  • If anxiety/depression or chronic functional symptoms are prominent, a psychiatrist, gastroenterologist, or primary clinician may consider a gut-brain neuromodulator, such as a low-dose tricyclic antidepressant or another appropriate antidepressant.
  • Avoid repeated, unsupervised antiemetic use, especially agents that can cause movement disorders or QT prolongation.
  • Avoid cannabis. If there is chronic cannabis exposure with episodic vomiting and hot-shower behavior, evaluate for cannabinoid hyperemesis and prioritize sustained cessation.
Evidence for psychotherapy, behavioral therapy and psychotropic agents is used clinically, although high-quality treatment evidence for functional vomiting remains limited. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, p. 217.

7. Follow-up

Review every 2 to 6 weeks initially:
  • Vomiting frequency, hydration, weight and nutritional intake
  • Potassium and renal function if vomiting continues or purging is possible
  • Mood, anxiety, suicidality, eating-disorder symptoms, cannabis use
  • Adherence to therapy and trigger-management plan
Reconsider the diagnosis and re-investigate if symptoms change, alarm features develop, weight falls, or the patient does not improve.

Documentation format

Record:
  • Medical causes considered and excluded
  • Red-flag screen
  • Eating-disorder, rumination and cannabis screen
  • CNVS/Rome criteria status
  • Psychological comorbidities and safety assessment
  • Joint treatment plan, named follow-up clinician, and escalation plan
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