psychogenic nausea and zoloft

[sophiedog]

After many  tests with GI specialists (we've been to two at two major hospitals in Boston) it has been concluded that my 13 yr-old son has pyschologically related nausea (no vomiting).  He was put on 25 mg zoloft last June and by July was fine but not sleeping well.  At the end of the summer his psychiatrist decided to put him on lexipro (off zoloft) to see if it would help sleeping issues.  He went right back to full-blown nausea and we are back on zoloft (just at the 3 wk. mark).  He is still very nauseous and missing 50% of school.  Getting very discouraged.  We will be seeing new psychiatrist this week and GI spec. early Nov. My question - is there anything that can help this nausea if the zoloft doesn't work this time. And do you think I should look further into physical causes?  Zofran did't work - are there other meds to help nausea.

[Kevin Kennedy, Ph.D.]

I actually would proceed on the medical front. I'm offering you this guidance because in almost every instance of this sort I have treated over a thirty-year span the ultimate improvement has been achieved under the care of pedi gastroenterologist.

[sophiedog]

My son has been on the zoloft 7 wks. now and the pyschiatrist has added 7.5 mg remeron at night (3 wks. now).  There is some improvement but he is still extremely nauseous in the AM and we are having a hard time getting him into school.  We have been trying to get him in 1 hour earlier each week.  This week is 10 AM.  Today, he went straight to the nurse when I dropped him off to lay down.  I feel awful about bringing him in to school when he feels this sick but all the docs, teachers and psychs tell me it's the best thing to do.  The remeron does help him sleep and usually increases his appetite but not consistently. The psych had me increase the remeron to 15 mg and he was a mess the next day with nausea and lethargy. I am hesitant about continuing the 15 mg.  They still feel that all his nausea is anxiety-driven and I'm just not seeing him as all that anxious.  You indicated that you think it is a default diagn.  I want to believe that the docs know best but I still am very confused about whether just sticking with their program or trying yet another specialist.  Who's left - I've been to NE Med Ctr and MGH.  What do you think?  Go with the current diagnosis or go for yet a third opinion?

[Kevin Kennedy, Ph.D.]

I can't comment on particular procedures, since it's not my area of expertise. But unless the symptom occurs only when there is some apparent secondary gain (e.g., to avoid particular activitie, responsibilities, interactions), I'd shy away from the psychogenic explanation. If it were psychogenic, it's not very likely he would have achieved benefit from the Zoloft (in any way that Celexa or Lexipro could not have provided).

[sophiedog]

Thank you for your thoughtful response.  To expand on this - do you think I should look at endocrinology?  Also, he has never had the gastric emptying test - his current GI thinks that it would be moot as he would have motility issues anyways due to his current illness.  Other doctors have recommended this test.  They have ruled out celiac with endoscopic biopsies, He's had brain MRI, nuero work-up, and several blood work-ups. He does have ADHD diagnosis and has had problems socially with peers - basically doesn't make friends - thus the psych diagnosis.  However, he has matured greatly and is tolerated much better by peers and is well-liked by teachers.  I know that his pyschological problems point to the conclusion Dr.'s have reached but I still think something else is going on.  Do you think I should ask for above tests and do you have any other recommendations.  Thanks so much for your help.

[Kevin Kennedy, Ph.D.]

Yes, there are alternatives to Zofran, and you are doing the sensible thing by consulting with different specialists. In thirty years of clinical practice I have seen a large number of children who have been diagnosed with psychogenic nausea or vomiting. To some extent these diagnoses are a default position - that is, in the absence of any specified physical cause, it is assumed that the symptom must be psychological. To tell you the truth, though, in each instance I have encountered I have not been able to support the diagnosis. Generally, the symptom has ultimately resolved when a physical cause has been located, and I think if you persist your son will be succesfully treated. And, his recent history bears this out - that is, if the symptom is psychogenic, why should it respond to Zoloft? Apparently he did achieve some relief. On hindsight, it's too bad the Zoloft was discontinued. Push ahead with your additional consults, and please kep us up to date with the results.