279
diuretic and delay ACE inhibitor therapy is no longer
supportable. 1. Smith WM. Epidemiology of
congestive heart failure. Am J Cardiol 1985;
55: 3A-8A. 2. Kannel WB, Cupples A. Epidemiology and risk profile of cardiac failure. Cardiovasc Drugs Ther 1988; 2: 387-95. 3. Sutton GC. Epidemiologic aspects of heart failure. Am Heart J 1990; 120:
1538-40. 4. The SOLVD investigators. Studies of left ventricular dysfunction (SOLVD)—rationale, design and methods: two trials that evaluate the effects of enalapril in patients with reduced ejection fraction. Am J Cardiol 1990; 66: 315-22. 5. The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med 1987; 316: 1429-35. 6. SOLVD investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293-302. 7. Cohn JN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991; 325: 303-10. 8. Cohn JN, Archibald DG, Ziesche S, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure. N Engl J Med 1986; 314: 1547-52. 9. Packer M, Lee WH, Yushak M, Medina N. Comparison of captopril and enalapril in patients with severe chronic heart failure. N Engl J Med 1986; 315: 847. 10. Cleland JGF, Dargie HJ, McAlpine H, et al. Severe hypotension after first dose enalapril in heart failure. Br Med J 1985; 291: 1309 - 12. 11. Hasford J, Bussmann W-D, Delius W, Koepcke W, Lehmann K, Weber E. First dose hypotension with enalapril and prazosin in congestive heart failure. Int J Cardiol 1991; 31: 287-94. 12. Di Bianco R. A large-scale trial of captopril for mild to moderate heart failure in the primary care setting. Clin Cardiol 1991; 14: 676-82.
Psychogenic vomiting—a disorder of gastrointestinal motility? For many people psychogenic vomiting is an occasional event associated with severe emotional stress. For a few continuing emotional conflicts lead to a syndrome of persistent or recurrent vomiting serious enough to require medical intervention. Such patients are commonly young or middle-aged women with a history of chronic and intermittent vomiting stretching back to childhood; their lives have often been blighted by bereavement, separation, or abuse.1-3 If one excludes patients with anorexia and bulimia nervosa, few of the remainder exhibit a serious psychopathological disorder. They tend to have rather rigid, passive personalities2 and an intense dislike of confrontation despite hostile relations with those close to them. Vomiting usually interrupts meals and is not associated with nausea or retching; patients can control the urge while they rush to the bathroom. Most patients do not lose weight and they have no abnormal physical signs; a few experience bouts of vomiting severe enough to cause dehydration and hypokalaemia. The vomiting has been variously described as a symbolic communication, a learned behaviour, a means of escape, a means of displacing anger, a somatic equivalent of anxiety, and a wilful manipulative action. Upper gastrointestinal symptoms including nausea and vomiting can now be investigated with various techniques to elucidate motility, including gastric
emptying studies,4,5 upper gastrointestinal manometry,5-7 and electrophysiological studies with
internal5,8 or surface electrodes.4 Hypomotility in the gastric antrum, abnormal gastric electrical activity known as gastric dysrrhythmia or tachygastria, and delayed gastric emptying have been reported in 50-100% of patients in various studies.4-8 There is no relation between the patients’ complaints and these motility disorders. Some patients with persistent abnormalities of gastrointestinal motility have only intermittent vomiting ;5 Gonzalez-Heydrich and colleagues9 describe a child in whom gastric emptying was delayed during stressful family circumstances but returned to normal once the stress had been removed. Abnormalities in gastrointestinal motility have also been induced in healthy controls during stress induced by limb cooling or vertigo. 10 The neurohormonal basis of disordered motility continues to interest researchers’ 1,12 but there have been few attempts to relate disordered motility to a clinical diagnosis of psychogenic
vomiting. 13 It is time to abandon the belief that psychogenic vomiting is a diagnosis to be considered only after organic disorders have been excluded.1.14 We should work on the basis that each individual has the potential
experience vomiting, perhaps secondary to disorders of gastrointestinal motility as a result of psychological stress, but that the threshold varies from one person to another. Those presenting with unexplained vomiting may be experiencing high levels of stress or have a low threshold. This hypothesis to
could be extended to suggest that certain upper gastrointestinal abnormalities such as gastritis or gastro-oesophageal reflux might lower the threshold for stress-related vomiting. 1. Wruble LD, Rosenthal RH, Webb WL. Psychogenic vomiting—a review. Am J Gastroenterol 1982; 77: 318-21. 2. Morgan HG. Functional vomiting. J Psychosom Res 1985; 29: 341-52. 3. Hill OW. Psychogenic vomiting. Gut 1968; 9: 348-52. 4. Geldoff H, Van der Schee EJ, Van Brankenstein M, Grashuis JL. Electrogastrographic study of gastric myoelectrical activity in patients with unexplained nausea and vomiting. Gut 1986; 27: 799-808. 5. Abell TL, Kim CH, Malagelada J-R. Idiopathic cyclic nausea and vomiting-a disorder of gastrointestinal motility? Mayo Clin Proc 1988; 63: 1169-75. 6. Malagelada J-R, Stanghellini V. Manometric evaluation of functional upper gut symptoms. Gastroenterology 1985; 88: 1223-31. 7. Kerlin P. Postprandial antral hypomotility in patients with idiopathic nausea and vomiting. Gut 1989; 30: 54-59. 8. You CH, Lee KY, Chey WY. Electrogastric study of patients with unexplained nausea, bloating and vomiting. Gastroenterology 1980; 79: 311-14. 9. Gonzalez-Heydrich J, Kerner JA, Steiner H. Testing the psychogenic vomiting diagnosis: four pediatric patients. Am J Dis Child 1991; 145: 913-16. 10. Stanghellini V, Malagelada J-R, Zinzmeister AR, et al. Stress induced gastroduodenal motor disturbances in humans—possible humoral mechanisms. Gastroenterology 1983; 85: 83-91. 11. Greydanus MP, Vassallo M, Camilleri M, Nelson DK, Hanson RB, Thomforde GM. Neurohormonal factors in functional dyspepsia: insights on pathophysiological mechanisms. Gastroenterology 1991; 100: 1311-18. 12. Camilleri M, Foeley RD. Idiopathic autonomic denervation in eight patients presenting with functional gastrointestinal disease: a causal association. Dig Dis Sci 1990; 35: 609-16. 13. Clouse RE, Lustman PJ. Psychiatric illness and contraction abnormalities of the esophagus. N Engl J Med 1983; 309: 1337-42. 14. Hanson JS, McCallum RW. The diagnosis and management of nausea and vomiting: a review. Am J Gastroenterol 1985; 80: 210-18.
diuretic and delay ACE inhibitor therapy is no longer
supportable. 1. Smith WM. Epidemiology of
congestive heart failure. Am J Cardiol 1985;
55: 3A-8A. 2. Kannel WB, Cupples A. Epidemiology and risk profile of cardiac failure. Cardiovasc Drugs Ther 1988; 2: 387-95. 3. Sutton GC. Epidemiologic aspects of heart failure. Am Heart J 1990; 120:
1538-40. 4. The SOLVD investigators. Studies of left ventricular dysfunction (SOLVD)—rationale, design and methods: two trials that evaluate the effects of enalapril in patients with reduced ejection fraction. Am J Cardiol 1990; 66: 315-22. 5. The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med 1987; 316: 1429-35. 6. SOLVD investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293-302. 7. Cohn JN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991; 325: 303-10. 8. Cohn JN, Archibald DG, Ziesche S, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure. N Engl J Med 1986; 314: 1547-52. 9. Packer M, Lee WH, Yushak M, Medina N. Comparison of captopril and enalapril in patients with severe chronic heart failure. N Engl J Med 1986; 315: 847. 10. Cleland JGF, Dargie HJ, McAlpine H, et al. Severe hypotension after first dose enalapril in heart failure. Br Med J 1985; 291: 1309 - 12. 11. Hasford J, Bussmann W-D, Delius W, Koepcke W, Lehmann K, Weber E. First dose hypotension with enalapril and prazosin in congestive heart failure. Int J Cardiol 1991; 31: 287-94. 12. Di Bianco R. A large-scale trial of captopril for mild to moderate heart failure in the primary care setting. Clin Cardiol 1991; 14: 676-82.
Psychogenic vomiting—a disorder of gastrointestinal motility? For many people psychogenic vomiting is an occasional event associated with severe emotional stress. For a few continuing emotional conflicts lead to a syndrome of persistent or recurrent vomiting serious enough to require medical intervention. Such patients are commonly young or middle-aged women with a history of chronic and intermittent vomiting stretching back to childhood; their lives have often been blighted by bereavement, separation, or abuse.1-3 If one excludes patients with anorexia and bulimia nervosa, few of the remainder exhibit a serious psychopathological disorder. They tend to have rather rigid, passive personalities2 and an intense dislike of confrontation despite hostile relations with those close to them. Vomiting usually interrupts meals and is not associated with nausea or retching; patients can control the urge while they rush to the bathroom. Most patients do not lose weight and they have no abnormal physical signs; a few experience bouts of vomiting severe enough to cause dehydration and hypokalaemia. The vomiting has been variously described as a symbolic communication, a learned behaviour, a means of escape, a means of displacing anger, a somatic equivalent of anxiety, and a wilful manipulative action. Upper gastrointestinal symptoms including nausea and vomiting can now be investigated with various techniques to elucidate motility, including gastric
emptying studies,4,5 upper gastrointestinal manometry,5-7 and electrophysiological studies with
internal5,8 or surface electrodes.4 Hypomotility in the gastric antrum, abnormal gastric electrical activity known as gastric dysrrhythmia or tachygastria, and delayed gastric emptying have been reported in 50-100% of patients in various studies.4-8 There is no relation between the patients’ complaints and these motility disorders. Some patients with persistent abnormalities of gastrointestinal motility have only intermittent vomiting ;5 Gonzalez-Heydrich and colleagues9 describe a child in whom gastric emptying was delayed during stressful family circumstances but returned to normal once the stress had been removed. Abnormalities in gastrointestinal motility have also been induced in healthy controls during stress induced by limb cooling or vertigo. 10 The neurohormonal basis of disordered motility continues to interest researchers’ 1,12 but there have been few attempts to relate disordered motility to a clinical diagnosis of psychogenic
vomiting. 13 It is time to abandon the belief that psychogenic vomiting is a diagnosis to be considered only after organic disorders have been excluded.1.14 We should work on the basis that each individual has the potential
experience vomiting, perhaps secondary to disorders of gastrointestinal motility as a result of psychological stress, but that the threshold varies from one person to another. Those presenting with unexplained vomiting may be experiencing high levels of stress or have a low threshold. This hypothesis to
could be extended to suggest that certain upper gastrointestinal abnormalities such as gastritis or gastro-oesophageal reflux might lower the threshold for stress-related vomiting. 1. Wruble LD, Rosenthal RH, Webb WL. Psychogenic vomiting—a review. Am J Gastroenterol 1982; 77: 318-21. 2. Morgan HG. Functional vomiting. J Psychosom Res 1985; 29: 341-52. 3. Hill OW. Psychogenic vomiting. Gut 1968; 9: 348-52. 4. Geldoff H, Van der Schee EJ, Van Brankenstein M, Grashuis JL. Electrogastrographic study of gastric myoelectrical activity in patients with unexplained nausea and vomiting. Gut 1986; 27: 799-808. 5. Abell TL, Kim CH, Malagelada J-R. Idiopathic cyclic nausea and vomiting-a disorder of gastrointestinal motility? Mayo Clin Proc 1988; 63: 1169-75. 6. Malagelada J-R, Stanghellini V. Manometric evaluation of functional upper gut symptoms. Gastroenterology 1985; 88: 1223-31. 7. Kerlin P. Postprandial antral hypomotility in patients with idiopathic nausea and vomiting. Gut 1989; 30: 54-59. 8. You CH, Lee KY, Chey WY. Electrogastric study of patients with unexplained nausea, bloating and vomiting. Gastroenterology 1980; 79: 311-14. 9. Gonzalez-Heydrich J, Kerner JA, Steiner H. Testing the psychogenic vomiting diagnosis: four pediatric patients. Am J Dis Child 1991; 145: 913-16. 10. Stanghellini V, Malagelada J-R, Zinzmeister AR, et al. Stress induced gastroduodenal motor disturbances in humans—possible humoral mechanisms. Gastroenterology 1983; 85: 83-91. 11. Greydanus MP, Vassallo M, Camilleri M, Nelson DK, Hanson RB, Thomforde GM. Neurohormonal factors in functional dyspepsia: insights on pathophysiological mechanisms. Gastroenterology 1991; 100: 1311-18. 12. Camilleri M, Foeley RD. Idiopathic autonomic denervation in eight patients presenting with functional gastrointestinal disease: a causal association. Dig Dis Sci 1990; 35: 609-16. 13. Clouse RE, Lustman PJ. Psychiatric illness and contraction abnormalities of the esophagus. N Engl J Med 1983; 309: 1337-42. 14. Hanson JS, McCallum RW. The diagnosis and management of nausea and vomiting: a review. Am J Gastroenterol 1985; 80: 210-18.
