Nervous vomiting and nausea.

Vomiting is the expulsion of gastric and esophageal contents through the mouth (and sometimes the nasal passages) to the outside.

"Nervous vomiting" was first described by V. Stiler in 1884. It should be emphasized that to date 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 wide range of manifestations - from episodes of vomiting that do not affect the general condition of the patient, appetite and body weight, to persistent vomiting for many years, leading to large weight losses and gross disturbances in the electrolyte balance of the body. Vomiting in nervous anorexia and bulimia is not considered by us, since these are sufficiently outlined forms of the disease, requiring, as a rule, the competence of a psychiatrist.

Psychogenic vomiting is more common in patients of adolescence, young adulthood, and middle age; females predominate (5:1). As a rule, vomiting is quite persistent, stubborn, and bothers patients for many months and years. A detailed analysis allows us to establish the presence of vomiting periods in childhood. Usually, appetite and body weight are not changed, vomiting occurs most often after eating or due to emotional factors. Nausea may be absent. An important feature of psychogenic vomiting is the ability to control and delay it: patients have time to reach the toilet.

Patients often exhibit various types of emotional disorders and autonomic dysfunction. The phenomenon of vomiting is usually accompanied by numerous autonomic disorders: sweating, pale skin, pronounced general weakness, tachycardia or bradycardia, and decreased blood pressure. The above autonomic disorders are included in the clinical picture of vomiting in different ways and can be minimal when vomiting is a hysterical phenomenon and serves as a way for the patient to express emotions. Patients with psychogenic vomiting, as a rule, tolerate it easily, and the fear of a serious organic disease often arises in relatives rather than in the patients themselves.

The state of the vestibular apparatus is of great importance in the clinical manifestations and pathogenesis of vomiting. Its initial, constitutional hypersensitivity (patients did not tolerate vestibular loads well - swings, carousels, transport) in the situation of psychogenic disease can sharply increase, significantly including in 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 connection between vomiting and pain, with food intake, to take into account the frequency and periodicity of vomiting, provoking factors. A neurologist should know that in organic diseases of the nervous system, the phenomenon of vomiting has its own fairly characteristic features. For example, fountain vomiting is most often associated with increased intracranial pressure (cerebral vomiting) or with the presence of stenosis of the pyloric section of the esophagus. Morning vomiting is characteristic mainly of metabolic disorders (pregnancy, alcoholism, uremia, etc.). The appearance of vomiting an hour after eating may indicate the possibility of a peptic ulcer, gastric carcinoma, gallbladder disease and intestinal obstruction.

Analysis of vomit can also provide important information: undigested food residues may indicate esophageal obstruction, fecal odor - intestinal genesis of the disease. Vomiting combined with large amounts of saliva and fluid reflects a swallowing disorder, which may occur with damage to the bulbar part of the brainstem. Increased vomiting with head movement, when moving from a horizontal to a vertical position or vice versa should raise the idea of vestibular involvement (Meniere's disease, organic brain disease). In addition to the above properties of vomiting, which is usually combined with nausea, the patient also has other signs of the corresponding disease: systemic dizziness and hearing loss in Meniere's disease; the presence of general 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 use 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 abdominal pain.

The pathogenesis of psychogenic vomiting is multidimensional. Neurophysiological mechanisms underlying the gag reflex are associated with the function of the gag centers, which are located in the reticular formation system. At the bottom of the fourth ventricle, there is also a chemoreceptor trigger zone, which can activate the function of the gag center in response to various stimuli. The physiological act of vomiting consists of the sequential activation of a number of muscles according to a certain algorithm and achieving gastric reflux - throwing out the contents of the stomach into the lower part of the esophagus. Several concepts have been proposed to explain psychogenic vomiting. I. P. Pavlov proposed understanding psychogenic vomiting as a conditioned reflex. Clinical observations of recent years confirm this point of view. Psychogenic vomiting is considered to be a result of emotional disorders in the system of interpersonal disorders. Intense emotions such as resentment, anger, according to the mechanisms of unconscious symbolism, can be expressed in the occurrence of vomiting. At the same time, the presence of certain models (most often in the family) of response to stress is emphasized; thus, vomiting also occurs as a learned form of response.

Also emphasized are such important aspects of pathogenesis as the presence of emotional disorders, in particular depression and anxiety of a stressful nature.

Patients with psychogenic vomiting are passive in their personality traits, not inclined to confrontation, lacking in persistence and having certain difficulties in controlling anger. The appearance of vomiting has always been emphasized as a certain indicator of a psychological impasse. Invoking hysterical mechanisms to explain the pathogenesis of psychogenic vomiting requires a subtle analysis to understand the phenomenon of vomiting in the context of the patient's behavioral mechanisms; such analysis and evidence are quite difficult.

Nausea is an unpleasant sensation in the epigastric region (sometimes a feeling that the stomach cannot tolerate its contents and has a tendency to expel them), which is sometimes accompanied by salivation, nausea, pale skin, and in some cases the appearance of pre-fainting conditions.

Nausea is closely related to vomiting and often precedes it. However, within the framework of psychogenic vegetative disorders, nausea can be an independent, rather persistent and persistent manifestation.

A detailed anamnesis, as a rule, allows us to identify various psychogenic situations in these patients, the connection of nausea with experiences in conditions of various stresses, difficulties of life. Often the feeling of nausea is a habitual and stereotypical feeling for a specific patient, appearing, as a rule, in a situation of emotional stress.

Increased sensitivity of the vestibular apparatus (innate or acquired) sometimes plays a major role in the formation and subsequent psychological fixation of the sensation of nausea. The mechanisms of pathogenesis are largely identical to the pathogenesis of psychogenic vomiting; the principles of treatment are also largely similar.

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