Gastric Stasis and Vomiting: Behavioral Treatment

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1 GASTROENTEROLOGY 1982;83:684-8 CASE REPORTS Gastric Stasis and Vomiting: Behavioral Treatment PAUL R. LATIMER. LEON S. MALMUD. and ROBERT S. FISHER Departments of Psychiatry, Nuclear Medicine and Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania A patient is described in hom gastric stasis and vomiting of 28-yr duration ere successfully treated ith behavior therapy. Failure of conventional medical treatment in the face of continued vomiting led to consideration for surgery. The need for surgery as obviated by the successful application of exposure and response prevention, hich resulted in a complete elimination of vomiting. Changes ere produced. not only in the overt behavioral manifestation (vomiting) but in gastrointestinal motility as ell. Although there as a lag, gastric emptying returned to normal. The improvements ere maintained at over l-yr follo-up study. Given the complexity of the hormonal, neuronal, and myogenic systems controlling gastric emptying, it seems probable that gastric stasis represents a final common pathay rather than a unitary condition ith a single cause (1-4). Both antral pump failure and poor coordination beteen antral, pyloric. and duodenal motor activity may lead to the same end point. Therapeutic efforts have included the administration of pharmacologic agents such as bethanechol (5.6), a cholinomimetic agent, and metoclopramide (7,8) and domperidone (9.1). dopamine antagonists. Even surgical removal of the functional obstruction has been attempted (1-3). In many cases, these approaches to treatment have not been successful. The role of stress and maladaptive learning have received minimal attention in this syndrome. This is somehat surprising in vie of the fact that these factors are knon to have a potent effect on gastrointestinal physiology (11,12). More than half a century ago, Cannon described gastric stasis in both animals and humans in response to anxiety (13). The role ol Received September 4, Accepted April 7, Address requests for reprints to: Paul R. Latimer, M.D., Ph.D., Department of Psychiatry, Temple University School of Medicine, cia Eastern Pennsylvania Psychiatric Institute, 33 Henry Avenue, Philadelphia, Pennsylvania by the American Gastroenterological Association $2.5 maladaptive learning in a ide variety of medical disorders (e.g., asthma, epilepsy, chronic pain, tension headaches) has been recognized increasingly, and the use of behavior therapy in treating such disorders has recently spaned the field of behavioral medicine (14-16). Behavior therapy is the application of principles and techniques derived from the experimental analysis of behavior for the purpose of changing persistent un adaptive habits (17). For example. it is knon from animal experiments that physiologic responses, including gastrointestinal responses, can be learned. These responses may come to be elicited by a previously neutral stimulus hen this stimulus is paired ith a stimulus that innately evokes the response. When this response is aversive. the organism may learn other behavior that reduces the discomfort (avoidance or escape behavior). Avoidance behavior is reinforced by the reduction or elimination of the aversive state. Such learned responses are extinguished by repeatedly exposing the animal to the stimuli hich have corne to elicit them and by preventing the avoidance or escape behavior. These principles form the basis for exposure and response prevention, the behavioral treatment method described later in this paper. Although of potential value in many gastrointestinal disorders, the role of behavioral methods in the investigation and treatment of functional boel disorders has received the greatest attention (12,18-22). The purpose of this paper is to report a ell-documented case of gastric stasis that appeared to have its basis in maladaptive learning. This patient as treated successfully using behavior therapy. Case Report History M.G. as a 55-yr-old houseife ho as seen because of a l-yr history of vomiting undigested food. The vomiting as unrelated to the type of meal ingested and

2 September 1982 BEHAVIORAL TREATMENT OF GASTRIC STASIS 685 occurred frequently after drinking ater alone. Typically, episodes of vomiting ere preceded by epigastric pain, fullness, and belching. She denied hematemesis, heartburn, dysphagia, regurgitation, odynophagia, difficulty cheing food, recent specific dietary intolerence, change in boel habits, melena, hematochezia, anorexia, eight loss, and Raynaud's phenomenon. There as no history of abdominal surgery, nor as there a family history for diabetes mellitus. Upon closer questioning, her vomiting dated back to age 27 and had initially been attributed to pregnancy. Folloing delivery of a normal, full-term baby, postprandial vomiting continued to occur at a rate of approximately 2-3 times eekly. This pattern as consistent, eekly until about 1 yr before this evaluation, hen she began to vomit ithin 15 min after all eating and drinking. A single meal as frequently folloed by several episodes of vomiting. She had been treated intermittently ith antacids, cimetidine, probanthine, dicyclomine, bethanechol, isosorbide nitrate, and indomethacin ithout relief. At no time during those many years did she experience severe eight loss or require hospitalization for dehydration or metabolic disturbance. Physical Examination Physical examination as entirely normal; she eighed 139 lb. Of note, the abdomen as scaphoid ithout tenderness, guarding, or rigidity; there as no evidence of hepatosplenomegaly or abdominal masses; boel sounds ere normal; both pelvic and rectal examinations ere unremarkable; stools ere negative for occult blood and there as no evidence for diabetic retinopathy, neuropathy, or collagen vascular disease. Diagnostic Evaluation Laboratory tests included a normal hemoglobin, hematocrit, sedimentation rate, hite blood cell count and differential, serum electrolytes, blood urea nitrogen, blood sugar and oral glucose tolerance test, liver function tests, T4 and T3 uptake. A test for antinuclear antibody as negative, and chest x-ray as normal. Multiple upper gastrointestinal roentgenograms over the years had revealed a normal esophagus, stomach, and small intestine except for questionably delayed gastric emptying suggested by significant barium persisting in the stomach for up to 4 h. On one occasion, duodenal spasm as reported. Oral cholecystography demonstrated a normal gallbladder. Ultrasound examinations of the liver, gallbladder, and pancreas ere normal. Esophageal manometry as normal ith a resting loer esophageal sphincter pressure of 24 mmhg, normal postdeglutition relaxation of both upper and loer esophageal sphincters, and normally progressive esophageal contractions. Pyloric manometry revealed a resting pyloric pressure of 4 mmhg ith normal pyloric pressure responses to duodenal hydrochloric acid and olive oil. No abnormalities of duodenal or antral motility ere noted. Upper endoscopic examinations revealed normal esophageal, gastric, and duodenal mucosas to the second portion of the duodenum. No evidence of obstruc- tion at the gastroesophageal or duodenogastric junctions as noted. Esophageal and gastroesophageal scintigraphic evaluations ere normal. Hoever, several attempts to quantitate gastric emptying of a physiologic mixed solidliquid meal, utilizing 99mTc sulfur colloid-labeled chicken liver and 1111n diethylenetriaminepentaacetic acid-labeled ater ere unsuccessful. Within 15 min of meal ingestion, the meal as vomited. Of interest, no evidence for gastric emptying of the solid or liquid component of the test meal as noted ithin the 15 min of meal retention. Therapeutic Trials Attempts to treat the patient ith oral and subcutaneous bethanechol administered in doses up to 5 mg, 3 min before meals and ith metoclopramide 1 mg, 3 min before eating, ere unsuccessful. It as decided to consider a behavioral approach to treatment before resorting to surgical resection of the distal stomach as both a diagnostic and therapeutic measure. Behavioral Assessment The behavioral assessment included i n t e r v i e ~ ith the patient and her husband, self-report psychologic inventories, daily self-monitoring of diet and vomiting, and direct behavioral observation. Several facts suggested the appropriateness of behavior therapy. First, the patient revealed that she had alays been somehat self-conscious about her eight and that vomiting had, for years, occurred after ingesting foods hich she regarded as fattening, such as ice cream and cake. Despite the vomiting, she did not avoid these foods and as never markedly overeight or undereight. She denied ever inducing vomiting as a eight control measure. Second, the pattern and severity of vomiting seemed to change for the orse after a specific dietary incident hich occurred 1 yr earlier. While being entertained at a friend's home, she accepted and ate a roast chestnut rapped in bacon, even though she as sure she ould not like it. Shortly afterard, she vomited forcefully. This pattern continued to occur subsequently after all eating and drinking. Third, despite the pervasiveness of the problem, she had lost no eight and had never vomited in public. She did not find it necessary to avoid social occasions since she as alays able to reach a ashroom in order to vomit. The remainder of the history as unremarkable aside from symptoms of mild anxiety and depressions hich seemed related to her health. There ere no marital problems or major psychiatric illnesses. When intervieed alone, her husband confirmed this account in all essential points, including the description of vomiting, hich he had observed on many occasions. Daily monitoring of diet and vomiting revealed an unremarkable diet and about 5-6 episodes of vomiting daily (Figure 1). Psychometric inventories demonstrated that the patient as not significantly depressed, anxious, or neurotic, as measured by Beck Depression (23), Spielberger Anxiety (24), and Eysenck Personality scales (25).

3 686 LATIMER ET AL. GASTROENTEROLOGY Vol. 83, No.3 B A S E L I ~ EXPOSURE E A ~ O FOLLOW-UP less frequent (Figure 1). Successive sessions folloed the 56 R E S P PREVENTION O ~ S E same pattern ith progressive reductions in the intensity,;: 49 and duration of her reactions. As the patient improved, she as asked to deliberately do things she felt ould make it ;;= "- :: 42 more likely for her to vomit. This included such things as CD alking and touching her toes immediately after eating. ~ I :::J 35 At eek B, she as taken for a scintigraphic gastric 6 emptying test. A marked delay in gastric emptying of both (!) z i= 28 solids and liquids as demonstrated. The computerized ~ results of this scintigraphic study are shon (Figure 2). > 21 Unfortunately, 135 min after meal ingestion, the patient "- as moved into the aiting room here, in the presence of en 14 other aiting patients, she vomited vigorously. A gastric en scan as obtained immediately after vomiting and shoed c:: 7 that the stomach had emptied substantially. This event demonstrated that there ere limits to her control even in o ~ I < > - I } - O the - presence { I - of < strong > social sanctions, and that, hen she ~ T T ~ ~ ~ ~ ~ ~ ~ T T ~ ~ ~ ~ ~ r r r r, II did vomit, the stomach as emptied. WEEKS After 12 k and seven therapy sessions, no further Figure 1. Episodes of vomiting per eek during baseline (eeks progress seemed to be occurring and the patient continued 1-3), exposure and response prevention (eeks 3-15), to vomit tice daily. At this point, the importance of and follo-up (eeks 15-78). complete response prevention at home as reemphasized to the patient and her husband. In addition, she as instructed to carry out specific home therapy sessions each evening in hich she ould eat a dish of ice cream ith Behavioral Analysis and Treatment chocolate syrup and remain ith her husband ithout vomiting. She did this ith immediate results hich continued until vomiting as completely eliminated (Figure 1). It should also be mentioned that during the course of therapy the patient as encouraged and advised in more appropriate eight control methods; her eight remained unchanged folloing treatment and at 1-yr follo-up study. At eek 23, gastric emptying improved dramatically as demonstrated by gastric scintigraphy (Figure 2). Vomiting has not recurred in over 1 yr of follo-up; gastric emptying remains improved (Figure 2). We hypothesized that vomiting had occurred originally in association ith pregnancy, but had continued because it served to control eight. The eating of roasted chestnuts, hich ere personally distasteful to the patient, produced an unconditioned response of delayed gastric emptying and vomiting. This ne learning experience produced a response similar to that hich she had acquired during pregnancy and led to generalization of that response to all eating situations. The behavioral intervention chosen as exposure and response prevention. This treatment is possible hen the patient has some degree of control over a problem behavior hich occurs in response to predictable and specific circumstances. In this case, the patient as asked to eat and then encouraged not to vomit; vomiting as treated as an avoidance behavior. After fully explaining the rationale to the patient and her husband, it as agreed to have her eat and drink the minimal amount that she felt certain ould lead to vomiting; this as a 4 oz. can of grapefruit juice. No kidney basins, tissue paper, or other facilities ere made available for emesis. Although she drank the juice quite normally, a mild, dull epigastric pain as reported almost immediately. Within approximately 1 min, she began to belch and reported the desire to vomit. After 3 min the episode had terminated ithout emesis and she felt fine. Subsequent treatment sessions involved progressively larger meals and increasingly difficult foods, such as ice cream and cake. These meals at first elicited stronger and longer reactions, including actual regurgitation of food, hich as resalloed. She usually felt confident that she ould not vomit after about 1 h. We emphasized the importance of continuing until she as sure that vomiting ould not occur and she as instructed not to vomit at home beteen sessions. After the second treatment session, vomiting episodes ere dramatically Discussion This case report demonstrates that some patients ith symptomatic gastric stasis can be treated successfully using behavior therapy. Improvement can be achieved and documented, not only in the overt behavioral manifestations, such as vomiting, but also in objective measurements of gastrointestinal motor function, such as gastric emptying. The role of maladaptive learning in the genesis of this case of gastric stasis can only be inferred. Certainly, the successful therapeutic outcome does not firmly establish the association. There are a groing number of successful applications of behavioral principles and methods to the treatment of medical conditions hich are not learned, e.g., fecal incontinence (22), neuromuscular rehabilitation (26) and hypertension (27). The fact that an illness is amenable to the behavioral approach may not be obvious to the attending physician even after a comprehensive evaluation. It

4 September 1982 BEHAVIORAL TREATMENT OF GASTRIC STASIS 687 -WEEK8 oweek23 ~ W E78 E K 1 LIQUID COMPONENT SOLID COMPONENT 9 8 (!l ~ 7 ~ 6 >- I- --- CL ~ u...-.a'" : 4 I- ' (f) -' <[ 3... (!l 2 I 1 o o TIME AFTER MEAL INGESTION (MINUTES) Figure 2. Gastric emptying of a physiologic, mixed solid-liquid meal at varying times. Gastric emptying as quantitated at 8 k (e), 23 k (), and 78 k (.:.). Gastric emptying of the liquid component is shon in panel A and of the solid component in panel B. The ranges of normal gastric emptying of liquid and solids are designated by the stippled areas. is beyond the scope of this paper to offer general guidelines for deciding hen a behavioral treatment is appropriate. In this case, there ere specific features hich suggested a behavioral disorder and there as no specific disease entity to account for the symptoms. Selection of an appropriate behavioral regimen requires a thorough understanding of the behavioral aspects of each individual patient. This is true of most situations in hich behavior therapy has been applied successfully. Although the treatment described here is technically simple, its proper implementation requires familiarity ith behavioral principles. Internists may be best advised to collaborate ith clinical psychologists or psychiatrists in such instances. The importance of recognizing the behavioral aspects of a given condition in the selection of a treatment modality is obvious. If behavioral mechanisms are an important cause of motor dysfunction of the gastrointestinal tract, this must be considered in designing research protocols for their treatment. Gastric stasis is seen in a heterogenous population; if all patients ith stasis ere entered into a study of the therapeutic efficacy of a pharmacologic agent, this might substantially increase the variance in responsiveness and lead to inconclusive and conflicting results. A similar case can be made ith respect to the investigation and treatment of functional boel disorders in general (12,18). The integration of the behavioral and biomedical sciences is essential if e hope to understand and treat many of the common gastrointestinal disorders. References 1. Feldman M, Corbelt DB, Ramsey EJ, et al. Abnormal gastric function in longstanding, insulin dependent patients. Gastroenterology 1979;77: Malagelada JR, Rees WOW, Mazzotta LJ, et al. Gastric motor abnormalities in diabetic and postvagotomy gastroparesis: effect of metoclopramide and bethanechol. Gastroenterology 198;78: Fox S, Behar J. Pathogenesis of diabetic gastroparesis: a pharmacologic study. Gastroenterology 198;78: Schulze-Delrieu K. The study of gastric stasis: static no longer. Gastroenterology 198;78: Sheiner HJ, Catchpole BN. Drug therapy for post-vagotomy stasis. Br J Surg 1976;63: Vasconez LG, Adams JT, et al. Treatment of reluctant postvagotomy stoma ith bethanechol. Arch Surg 197;1: Eisner M. Effect of metoclopramide on gastrointestinal motility in man. A manometric study. Am J Dig Dis 1979;16: Perkel M, Moore C, et al. Metoclopramide therapy in patients ith delayed gastric emptying. Dig Dis Sci 1979;24: Reyntjens AJ. Domperidone, a novel and safe gastrokinetic anti-nauseant for the treatment of dyspepsia and vomiting. A survey of pharmacological and clinical results. Arzneim Forsch 1978;28: VanGanse W. Chronic dyspepsia: double-blind treatment ith domperidone or placebo. A multicenter therapeutic evaluation. Curr Ther Res Clin Exp 1978;23: Wolf S, Welsh JD. The gastrointestinal tract as a responsive system. In: Greenfield NS, Sternbach RA, eds. Handbook of psychophysiology. Ne York: Holt, Rinehart and Winston, Inc., 1972:

5 6e8 LATIMER ET AL. GASTROENTEROLOGY Vol. 83, No Latimer PRo Behavioral medicine and the functional gastrointestinal disorders. Ne York: Springer Publishing Co., (in press). 13. Cannon WB. Bodily changes in pain, hunger, fear and rage. 2nd ed. Ne York: Appleton-Century-Crofts, 1929: Pomerleau OF, Brady JP, eds. Behavioral medicine: theory and practice. Baltimore: Williams & Wilkins Co; Melamed BG, Siegel LJ. Behavioral medicine: practical applications in health care. Ne York: Springer Publishing Co., Latimer PRo Behavioral medicine: scope and definition. International J Ment Health 198;9: Wolpe J. The practice of behavior therapy. 2nd ed. Ne York: Pergamon Press, Inc., 1973:xi. 18. Latimer PR, Campbell D. Behavioral medicine and the functional boel disorders. Int J Ment Health ; 9 : ~ Latimer PRo Behavior therapy, biofeedback and the gastrointestinal tract. J Psychother Psychosom (in press). 2. Miller NE. Effect of learning on gastrointestinal functions. Clin Gastroenterol 1977;6: Almy TP. Therapeutic strategy in stress-related digestive disorders. Clin Gastroenterol 1977;6: Schuster MM. Biofeedback control of gastrointestinal motility. In: Basmajian JV, ed. Biofeedback-principles and practice for clinicians. Baltimore: Williams & Wilkins Co., 1979: Beck AT, Ward GH, Mendelson M, et al. An inventory for measuring depression. Arch Gen Psychiatry 1961;4: Spielberger CD, Gorsuch RL, Lushene RE. STAI manual. Palo Alto: Consulting Psychologists Press, Inc., Eysenck HJ, Eysenck SBG. Eysenck personality inventory. San Diego: Educational and Industrial Testing Service, Inglis J, Campbell D, Donald MW. Electromyographic biofeedback and neuromuscular rehabilitation. Can J Behav Sci 1976;8: Agras S, Jacob R. Hypertension. In: Pomerleau OF, Brady JP, eds. Behavioral medicine: theory and practice. Baltimore: Williams & Wilkins Co., 1979:25-32.

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