Anticipatory Nausea and Vomiting
Prevalence
Classical Conditioning
Variables Correlated with ANV
Treatment of ANV
Prevalence
The prevalence of anticipatory nausea and vomiting (ANV) has varied, owing to
changing definitions and assessment methods.[1] However, anticipatory nausea
(AN) appears to occur in approximately 29% of patients receiving chemotherapy,
or about 1:3, while anticipatory vomiting (AV) appears to occur in 11% of
patients, or about 1:10.[2] With the introduction of new pharmacologic agents
(5-HT3 receptor antagonists), it was anticipated that the prevalence of ANV
might decline; however, studies have shown mixed results. One study found a
lower incidence of ANV,[3] and three studies found comparable incidence
rates.[2,4,5] It appears that the 5-HT3 agents reduce postchemotherapy
vomiting, but not postchemotherapy nausea,[2,5] and the resulting impact on ANV
is unclear.
Classical Conditioning
Although other theoretical mechanisms have been proposed,[6] ANV appears to be
best explained by classical conditioning (also known as Pavlovian or respondent
conditioning).[7] In classical conditioning, a previously neutral stimulus
(e.g., smells of the chemotherapy environment) elicits a conditioned
response (e.g., ANV) after a number of prior pairings or learning trials. In
cancer chemotherapy the first few chemotherapy infusions are the learning
trials. The chemotherapy drugs are the unconditioned stimuli that elicit
postchemotherapy nausea and vomiting (in some patients). They are paired with
a variety of other neutral, environmental stimuli (e.g., smells of the setting,
oncology nurse, chemotherapy room). These previously neutral stimuli then
become conditioned stimuli and elicit ANV in future chemotherapy cycles. ANV
is not an indication of psychopathology, but rather a learned response that, in
other life situations (e.g., food poisoning) results in adaptive avoidance. A
variety of correlational studies provide empirical support for classical
conditioning. For example, the prevalence of ANV prior to any chemotherapy is
very rare, and few patients ever experience ANV without prior postchemotherapy
nausea.[8] Also, most studies have found a higher probability of ANV with
increasing numbers of chemotherapy infusions, and the intensity of ANV
increases as patients get closer to the actual time of their infusion.[9] In
one experimental study, it was shown that a novel beverage could become a
conditioned stimulus to nausea when paired with several chemotherapy
treatments.[10]
Variables Correlated with ANV
Many variables have been investigated as potential factors that correlate with
the incidence of ANV in hopes of developing a list of risk factors. There is
currently no agreement on which factors predict ANV. A patient with fewer than
three of the first eight characteristics listed below, however, is unlikely to develop ANV, and
screening following the first chemotherapy infusion could identify those
patients at increased risk.[11]
Variables Found to Correlate With ANV
- Age younger than 50 years.
- Nausea/vomiting after last chemotherapy session.
-
Posttreatment nausea described as moderate, severe, or intolerable.
- Posttreatment vomiting described as moderate, severe, or intolerable.
- Feeling warm or hot all over after last chemotherapy session.
-
Susceptibility to motion sickness.
- Sweating after last chemotherapy session.
- Generalized weakness after last chemotherapy session.
- Female gender.
- High-state anxiety (anxiety reactive to specific situations).[12,13]
- Greater reactivity of the autonomic nervous system and slower reaction
time.[14]
- Patient expectations of chemotherapy-related nausea before beginning
treatment.[15,16]
- Percentage of infusions of chemotherapy followed by nausea.[17]
- Postchemotherapy dizziness.
- Lightheadedness.
- Longer latency of onset of
posttreatment nausea and vomiting.[18]
- Emetogenic potential of various chemotherapeutic agents. Patients receiving drugs with a moderate-to-severe potential for
posttreatment nausea and vomiting are more likely to develop ANV.[12]
- Morning sickness during pregnancy.
Treatment of ANV
Antiemetic drugs do not seem to control ANV once it has developed;[2] however,
a variety of behavioral interventions have been investigated.[19] These
include progressive muscle relaxation with guided imagery,[20] hypnosis,[21]
systematic desensitization,[22] electromyography (EMG) and thermal biofeedback,[23] and
distraction via the use of video games.[24,25] Progressive muscle relaxation
with guided imagery, hypnosis, and systematic desensitization has been studied
the most and is the recommended treatment. Referral to a psychologist or
other mental health professional with specific training and experience in
working with cancer patients is recommended when ANV is identified. The
earlier it is identified, the more likely treatment will be effective, and
thus early screening and referral are essential.
In addition, physicians and nurses underestimate the incidence of chemotherapy-induced nausea and vomiting.[26]
References
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Morrow GR, Roscoe JA, Hickok JT: Nausea and vomiting. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 476-484.
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Roscoe JA, Morrow GR, Hickok JT, et al.: Biobehavioral factors in chemotherapy-induced nausea and vomiting. Journal of the National Comprehensive Cancer Network 2 (5): 501-8, 2004.
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