Can psych-related vomiting be referred to as cyclical vomiting syndrome (CVS) and how is it managed?

Cyclic Vomiting Syndrome: Psychiatric Connections and Management

Yes, psychologically-related vomiting can be classified as cyclic vomiting syndrome (CVS) when it presents with stereotypical episodes of acute-onset vomiting separated by symptom-free intervals, particularly when associated with mood disorders like anxiety, depression, and panic disorder which are present in 50-60% of CVS patients. 1

Diagnostic Criteria for CVS

CVS is diagnosed based on the Rome IV criteria, which includes:

• Stereotypical episodes of acute-onset vomiting lasting <7 days 1
• At least 3 discrete episodes in a year, with 2 occurring in the prior 6 months 1
• Episodes separated by at least 1 week of baseline health 1
• Absence of vomiting between episodes (though milder symptoms like nausea may persist) 1

Psychiatric Connections to CVS

The relationship between psychiatric conditions and CVS is significant:

• Mood disorders including anxiety, depression, and panic disorder are present in 50-60% of CVS patients 1
• Psychological stressors are common triggers for CVS episodes 2, 3
• Many patients experience prodromal anxiety and panic before episodes begin 1
• During the prodromal phase, patients may report an "impending sense of doom" 1

Management Approach for Psychologically-Related CVS

1. Severity Assessment

• Classify as mild CVS (<4 episodes/year, each lasting <2 days, no ED visits) or moderate-severe CVS (≥4 episodes/year, lasting >2 days, requiring ED visits) 1

2. Treatment Strategy Based on Severity

For mild CVS:

• Focus on abortive treatment during episodes 1
• Address psychological triggers 2

For moderate-severe CVS:

• Implement both prophylactic and abortive treatments 1
• Psychiatric co-management is essential 2

3. Pharmacological Management

Prophylactic therapy (for moderate-severe CVS):

• Tricyclic antidepressants (TCAs) are first-line treatment 1, 4
  • Amitriptyline: Start at 25 mg at bedtime, target 75-150 mg or 1-1.5 mg/kg 1
  • Nortriptyline: Alternative with potentially fewer anticholinergic side effects 1
  • TCAs show 67-75% response rates in clinical studies 5

Abortive therapy (for all CVS patients):

• Triptans (e.g., sumatriptan) have shown effectiveness in adults 5
• Benzodiazepines like lorazepam may help, particularly for anxiety-triggered episodes 6

4. Addressing Psychiatric Comorbidities

• Treatment of underlying anxiety and depression can decrease frequency of CVS episodes 1
• Multidisciplinary management including psychiatric care leads to faster and more sustained recovery 2
• Cognitive-behavioral therapy may help manage psychological triggers 2

Important Clinical Considerations

• CVS is often misdiagnosed, with patients experiencing diagnostic delays of several years 1, 6
• Psychiatric symptoms may be mistaken as the cause rather than a comorbidity of CVS 2
• Hot water bathing/showering for symptom relief is common in CVS (48% of non-cannabis users) and is not exclusive to cannabinoid hyperemesis syndrome 1
• Some patients may develop "coalescent CVS" with progressively fewer symptom-free days, eventually leading to daily symptoms 1

Common Pitfalls to Avoid

• Dismissing physical symptoms as "just psychological" without proper evaluation 2
• Failing to recognize the stereotypical pattern of episodes, which is key to diagnosis 1
• Missing the opportunity to treat during the prodromal phase, when abortive therapy is most effective 1
• Overlooking the high prevalence of CVS (approximately 2% of the US population) due to poor recognition 1
• Not addressing both the physical and psychological aspects of the condition 2

By recognizing the psychiatric connections to CVS while treating it as a legitimate medical condition, clinicians can significantly improve outcomes and quality of life for these patients.