There is often a close association between anxiety and nausea and vomiting.  Two common situations are:

Anticipation

Commonly occurs when there is a stong association between an emetogenic stimulus such as chemotherapy and a specific environment such as oncology outpatients, in which sight, sound and especially smell combine to reinforce the association over succeeding visits.  The association between environment, event and emesis needs to be broken.  This can be done using:

• Play or psychotherapy
• Hypnotherapy
• Medications that attenuate the experience of anxiety, particularly Nabilone (mildly euphoric derivative of marijuana with sedative and antiemetic properties) and benzodiazepines.
• Complementary therapies.

Generalised anxiety

The above measures may be used.  Benzodiazepines (see below) are anxiolytic, where soporifics (e.g. Chloral Hydrate, Levomepromazine) are not.

• Midazolam.  Can be given parenterally or buccally.  Advantage:  rapid onset, short acting, amnesic.  Disadvantage:  may be so short acting that it does not encompass whole stressful episode.
• Lorazepam.  May be given orally, parenterally or sublingually.  Adantage:  Longer acting, can have rapid onset if given sublingually.  Disadvantage:  Long duration of action may not always be desirable.
• Diazepam.  Can be given orally or parenterally or rectally.  Advantage:  Longer acting.  Disadvantage:  Long duration of action may not always be desirable.

In general, as with most medications for managing psychological aspects of illness, they should not be prescribed alone but in association with appropriate non-drug techniques.

Palliative medicine concerns patients in whom:

• Anxiety levels are often high.
• There may be a multiplicity of physical factors.
• Effective management of the symptoms requires attention to all dimensions.

This means:

• It is important to explore the expectations of the patient and family before embarking on treatment.
• It is important to be realistic about what can be achieved.
• Even with optimal pharmacological and psychological support, it is not always possible to abolish nausea and vomiting entirely.
• For most patients, reducing the frequency of vomiting to once or twice a day may be enough.
• As always, need to balance the likely impact of antiemetic therapy against the potential adverse effects.  The balance of burden and benefit for individual families needs to be established before embarking on treatment.