Weekly Mind Reader: When is Vomiting Not a Gut Problem?

The latest issue of Weekly Mind Reader includes a case report of chronic vomiting covering for something else, a review of the economic impact of schizophrenia and cognitive impairment, and how apps can advance – and maybe hinder – psychiatric care.

When It’s a Panic Attack.

Panic attacks, notable for their abrupt, acute episodes of unreasonable fear or stifling discomfort, normally peak quickly and gradually fade away. Other symptoms can include a racing heart, sweating, trembling, shortness of breath, chest pain, dizziness, and a sense of losing control or dying. While these are the obvious hallmarks of a panic attack, they overlook a lesser-known symptom: intractable vomiting.

A new report in The Primary Care Companion for CNS Disorders details the strange case of a 19-year-old man who wrestled with bouts of recurrent vomiting at 16. The disruptive outbursts dovetailed with a nerve-racking school change. Despite exhaustive medical assessments, which included blood tests, electroencephalography, and endoscopy, his doctors failed to pin down a physical cause.

The vomiting persisted and even included hematemesis. This shook up the patient’s life. It kept him from attending class while forcing him to pull back from social situations. He continued to struggle with symptoms of nausea, palpitations, and bouts of intense fear before each episode. Antiemetic medications did little to help.

Finally, a psychiatric consultation revealed a panic disorder diagnosis. Consequently, doctors prescribed treatment that included paroxetine, a selective serotonin reuptake inhibitor (SSRI), and clonazepam. As a result, the vomiting abated, and the young man returned to class and a teenager’s typical social life.

However, when doctors cut off the treatment, the symptoms returned. But the reintroduction of the drug regime alleviated them once again.

This case illustrates the importance of considering panic attacks as a factor in patients with baffling gastrointestinal symptoms. It also reinforces the complicated relationship between anxiety disorders and digestive issues. It also affirms the need for psychiatric evaluation once you can rule out any physical causes.

The successful use of paroxetine shows how well it can manage even the most atypical manifestations of panic disorder.

IN OTHER PSYCHIATRY AND NEUROLOGY NEWS

• A review appearing in The Journal of Clinical Psychiatry reveals that patients with schizophrenia and cognitive impairment had a 100 percent increase in relapse-related hospitalizations and ER visits versus patients with little-to-no cognitive impairment.
• In a new letter to the editor of APCC, readers discuss the advancements – and risks – in psychiatry smartphone applications.
• Also in JCP, Dr. Andrade discusses two RCTs that investigated the utility of olanzapine and mirtazapine in addressing appetite loss in cancer patients.
• A JCP commentary piece by Dr. Rosenbaum remarks on the challenge of evaluating trials of treatments whose effects are unmistakable.
• And, finally, this week saw the launch of our new ongoing series of research reviews on PTSD and trauma.