Vomiting is the eruption of gastric and esophageal contents through the mouth (sometimes nasal passages) outward.
For the first time "nerve vomiting" was described by V. Stiler in 1884. It should be emphasized that for today there is no sufficiently clear and unambiguous description of the clinical picture of this phenomenon within the framework of psychogenic disorders. Vomiting of a psychogenic nature can have an unusually large range of manifestations - from episodes of vomiting that do not affect the patient's general condition, appetite and body weight, to persistent long-term vomiting, leading to large mass losses and gross violations of the electrolyte balance of the body. Vomiting with anorexia nervosa and bulimia is not considered by us, as these are sufficiently outlined forms of the disease, requiring, as a rule, the competence of a psychiatrist.
Psychogenic vomiting is more common in young, young and middle-aged patients; the female sex prevails (5: 1). As a rule, vomiting is persistent enough, persistent, worries patients for many months and years. Detailed analysis allows to establish the presence of periods of vomiting in childhood. Usually, appetite and body weight are not changed, vomiting occurs more often after eating or in connection with emotional factors. Nausea may be absent. An important feature of psychogenic vomiting is the availability of control and delay capabilities: patients manage to reach the toilet.
Often, patients are exposed to various variants of emotional disorders, autonomic dysfunction. The phenomenon of vomiting is usually accompanied by numerous vegetative disorders: sweating, paleness of the skin, pronounced general weakness, tachycardia or bradycardia, a decrease in blood pressure. These autonomic disorders are included in the clinical picture of vomiting differently and may be minimal when vomiting is a hysterical phenomenon and serves as a way of expressing emotions in a patient. Patients with psychogenic vomiting, as a rule, easily tolerate it, and the fear of a serious organic disease often occurs in relatives, and not in the patients themselves.
Great importance in the clinical manifestations and pathogenesis of vomiting has a state of the vestibular apparatus. Its initial, constitutional hypersensitivity (the patients did not tolerate vestibular loads - swings, carousels, transport) in the situation of psychogenic illness can dramatically increase, significantly including the mechanism of symptom formation.
The diagnosis of psychogenic vomiting is very responsible, therefore a detailed analysis of the phenomenon is required. It is always necessary to clarify the relationship of vomiting with the presence of pain, with food intake, take into account the frequency and frequency of vomiting, provoking factors. The neurologist should know that with organic diseases of the nervous system, the phenomenon of vomiting has its own rather distinctive features. For example, fountain vomiting is most often associated with increased intracranial pressure (cerebral vomiting) or with stenosis of the pyloric section of the esophagus. Morning vomiting is characteristic mainly for metabolic disorders (pregnancy, alcoholism, uremia, etc.). The appearance of vomiting one hour after ingestion may indicate the possibility of peptic ulcer, gastric carcinoma, gallbladder disease and intestinal obstruction.
Analysis of vomit can also give important information: the remains of unboiled food can indicate obstruction of the esophagus, fecal odor - on the intestinal genesis of the disease. Vomiting, in conjunction with a large saliva, fluid reflects a violation of swallowing, which can occur when the bulbar of the brainstem is affected. Increased vomiting when moving the head, when moving from a horizontal position to a vertical position or vice versa, should cause the idea of vestibular involvement (Meniere's disease, organic brain disease). In addition to these properties of vomiting, which, as a rule, is combined with nausea, the patient also has other signs of the corresponding disease: systemic dizziness and hearing loss in Meniere's disease; presence cerebral and local signs of brain damage in a neurological disease.
Nausea and vomiting along with dizziness are frequent companions of migraine attacks.
Important for the diagnosis of psychogenic vomiting is the application of criteria that would prove a high probability of the psychogenic nature of the disorder. For practical purposes it seems appropriate to use the same criteria that are used in the diagnosis of psychogenic pain in the abdomen.
The pathogenesis of psychogenic vomiting is multidimensional. Neurophysiological mechanisms underlying the emetic reflex are associated with the function of vomiting centers that are located in the system of the reticular formation. At the bottom of the IV ventricle there is also a chemoreceptor trigger zone, which can activate the function of the vomiting center in response to various stimuli. The emetic physiological act consists in the sequential inclusion of a certain algorithm of a number of muscles and the achievement of gastric reflux - the discharge of the contents of the stomach into the lower part of the esophagus. Several concepts have been proposed to explain psychogenic vomiting. IP Pavlov proposed an understanding of psychogenic vomiting as a conditioned reflex. Clinical observations of recent years confirm this point of view. Consider psychogenic vomiting as a result of emotional disorders in the system of interpersonal disorders. Intensive emotions such as resentment, anger by the mechanisms of unconscious symbolism can be expressed in the occurrence of vomiting. It emphasizes the presence of certain models (most often in the family) of responding to stress; Thus, vomiting also appears as a trained form of reaction.
Important aspects of pathogenesis, such as the presence of emotional disorders, in particular depression, anxiety of a stressful nature, are also emphasized.
Patients with psychogenic vomiting for their personal characteristics are passive, not inclined to confrontation, do not have enough perseverance and have certain difficulties in containing anger. Always stressed the emergence of vomiting as a measure of psychological impasse. Attraction of hysterical mechanisms to explain the pathogenesis of psychogenic vomiting requires a subtle analysis to understand the phenomenon of vomiting in the context of the mechanisms of the patient's behavior; Such analysis and proof are rather difficult.
Nausea is an unpleasant sensation in the epigastric region (sometimes the feeling that the stomach does not tolerate its contents and tends to be excreted outwardly), which is sometimes accompanied by drooling, faintness, pallor of the skin, and in some cases by the appearance of pre-stupor states.
Nausea is closely related to vomiting and often precedes it. However, within the framework of psychogenic autonomic disorders, nausea can be an independent, rather persistent and persistent manifestation.
The detailed anamnesis, as a rule, allows to reveal at the given patients various psychogenic situations, communication of a nausea with experiences in the conditions of various stresses, difficulties of a life. Often the feeling of nausea is in a particular patient a habitual and stereotyped feeling that appears, as a rule, in a situation of emotional stress.
The increased sensitivity of the vestibular apparatus (congenital or acquired) is sometimes of great importance in the formation and subsequent psychological fixation of a feeling of nausea. Mechanisms of pathogenesis are largely identical with the pathogenesis of psychogenic vomiting; the principles of treatment are also very similar.
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