Conversion disorder with psychogenic vomiting and coexisting organic etiology in an adolescent: A case report

Psychogenic vomiting is an uncommon, often overlooked condition linked to psychosocial stressors, without an obvious organic cause [1]. The most common diagnosis for patients with habitual postprandial or irregular vomiting is major depressive disorder (MDD), whereas conversion disorder is the most common diagnosis for patients with chronic vomiting [1, 2]. Unfortunately, psychogenic vomiting is not well addressed in the Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5) and International Classification of Diseases-11th Revision (ICD-11), creating diagnostic challenges [3].

This case study examines an adolescent girl with persistent vomiting who, after diagnostic challenges, responded well to psychiatric intervention.

This case report highlights the diagnostic and therapeutic challenges associated with conversion disorder overlapped with organic causes in an adolescent presenting with psychogenic vomiting. The report emphasizes the importance of early identification and holistic management of conversion disorder, utilizing multidisciplinary intervention, drugs, psychotherapy, and stress management techniques, based on clinical criteria and psychological assessment.

A 13-year-old eighth grader presented to the Department of Gastroenterology at Bangabandhu Sheikh Mujib Medical University following 3 months of recurrent vomiting and fatigue. She started off with infrequent but increasingly frequent episodes of vomiting, which would happen 10-15 times daily, usually in the hours following a meal or drink. The vomitus consisted of freshly consumed food, with no blood or bile, and did not improve with medication. There were no other gastrointestinal symptoms, headache, or weight loss. She had regular menstrual cycles with moderate flow. Her body mass index was 18.6 kg/m², placing her at the 50th percentile. Upon examination, the patient was normotensive, with tachycardia and mild dehydration. There were no signs of skin hyperpigmentation, calluses on knuckles, and tooth erosion. Her neurological examination was normal. Despite consulting multiple specialists, none of the treatments provided significant relief. She was also using salbutamol and fluticasone inhalers for her bronchial asthma, diagnosed five years earlier and currently in remission.

The findings of laboratory testing, such as a complete blood count, electrocardiogram, metabolic panel, and radiographic investigations (including barium swallow), were normal. Endoscopic assessment showed non-specific gastritis. Initial laboratory results showed low adrenocorticotrophic hormone (ACTH) (3.55 pg/ml) and basal cortisol (8.30 μg/dl), with cortisol levels rising to 9.5μg/dl one hour after ACTH injection. Other hormone reports were normal.

Glucocorticoid-induced adrenal insufficiency, which was discovered upon referral to endocrinology, was probably brought on by her previous use of steroids. The clinician initially ordered hydrocortisone injection; however, this was later changed to oral hydrocortisone. One month later, hydrocortisone was stopped when cortisol levels were 14.32 μg/dl. However, her vomiting persisted, and suddenly, within 24 days of admission, she developed frequent asynchronous limb movements without bladder or bowel involvement. Neurological evaluations identified psychogenic non-epileptic seizures (PNES). Symptomatic treatment offered no improvement.

Despite improvements in adrenal function and gastritis management, her symptoms worsened. This suggested that a complex psychological or functional component may be contributing.

A psychiatry consultation eventually diagnosed her with conversion disorder, presenting with a combination of symptoms according to DSM-5. Psychiatric assessment highlighted preoccupation with illness, feelings of helplessness, and moderate stress, with no significant family history of psychiatric disorders. She never self-induced the vomiting and thought her weight was ordinary. The treatment plan combined pharmacotherapy with supportive psychotherapy, relaxation techniques, stress management, and cognitive restructuring. Psychoeducation was provided to both the patient and her mother. No adverse events were reported during treatment.

After 2 months of treatment, the patient’s symptoms improved. She returned to full-time school attendance and demonstrated improved social interactions and emotional well-being. Follow-up sessions confirmed sustained symptom remission.

We would like to express our gratitude to Dr. Md. Farid Uddin, Professor of Endocrinology at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, for his invaluable assistance with the diagnosis, treatment. We would also like to thank the patient and her family members for their cooperation.

Manuscript drafting and critical revision: TA, SES, ABA. Approval of the final version of the manuscript: NMM, SES. Guarantor of accuracy and integrity of the work: TA, SRJ.

We do not have any conflict of interest.

We confirm that the data supporting the findings of the study will be shared upon reasonable request. 

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