Emetophobia Treatment

Emetophobia Counselling

Emetophobia or ‘vomiting phobia’ (fear of vomiting) is the extreme fear of sickness and vomiting. There hasn’t been a whole lot of literature and research on the condition, which is surprising given how many people complain about emetophobia symptoms. Prevalence ranges from 1.7% to 3.1% for males and from 6% to 7% for females (Phillips, 1985; von Hout & Bouman, 2006). Similar to people diagnosed with an anxiety disorder, many individuals who experience difficulties with emetophobia describe performing safety-seeking and avoidance behaviours. For example, many people diagnosed with emetophobia would describe avoiding seafood, not eating at restaurants that have poor reviews, or staying away from sick people. Individuals who have emetophobia may also have had negative experiences from vomiting or seeing others vomit which may have triggered the onset of the condition. The onset may also follow medical illness which may have influenced the sufferer to become hypervigilant around bodily sensations around their stomach.

How is the Emetophobia maintained?

Perceptions of others being sick may also lead to further anxiety, which may only increase stomach sensations and thoughts that the sufferer may throw up. The thoughts could further increase anxiety leading to an escalation in gastrointestinal (stomach sensations) symptoms that the sufferer may be sensitive to thus increasing their fear that they may vomit. Avoidance behaviours such as avoiding certain foods or nausea avoidance altogether will only further increase the fear of vomiting. Safety behaviours such as carrying gravel will also further increase the fear and make it more difficult to learn to manage the anxiety. Put simply safety behaviours and avoidance increase the anxiety and will only maintain the emetophobia. Therapy will help reduce the safety and avoidance behaviours in an effort to help the patient ready themselves for exposure.

How does the treatment of Emetophobia compare to IBS treatment?

Many people who experience emetophobia describe performing checking behaviours around their stomach. Similarly, people with Irritable Bowel Syndrome (IBS) do the same. Both conditions are described as a persistent chronic course without periods of remission in symptoms. Just like IBS, physiological arousal plays a key role in emetophobia and can be the hallmark symptom of the disorder. Individuals with emetophobia are more likely to report higher scores on measures of sensitivity to body sensations compared to a group of non-sufferers. Similarly, as IBS patients check their stomach for distressing symptoms emetophobia sufferers often do the same. This behaviour may influence neural activity in the areas they check (the stomach), thus making them more sensitive to upset stomach cues than non-sufferers. In treatment, meditation and mindfulness has demonstrated to be quite effective in managing with the stomach hypersensitivity and attention issues emetophobia sufferers experience difficulties with.

Emetophobia by Proxy

Emetophobia by Proxy (EP) is a variant of emetophobia in which the anxiety involves others vomiting. I coined this term fairly recently, so there isn't any literature on the term. Most people with emetophobia by proxy will struggle when others vomit and will perform safety behaviours to avoid situations or people who may be ill. At first glance of the subtypes, people with emetophobia by proxy will not be able to align themselves with any emetophobia subtypes. However, when you probe the individual and use the downward arrow technique (as discussed in cognitive therapy research) they eventually fit within one OR MORE of the subtypes.

Emetophobia Subtypes

Subtype #1 - Social phobia-like factors

Some emetophobia sufferers may also describe having a heightened sense of sensitivity to the opinion of others. They may describe fearing being negatively evaluated if they are sick. Part of the work in therapy may be evaluating for such fears and creating a specific treatment plan to challenge negative thinking around evaluation and preparing specific exposure-like activities that would help reduce the fear.

Subtype #2 - OCD subtype

Individuals with OCD may also present with symptoms of emetophobia. This needs to be carefully evaluated out by your practitioner. People with the OCD subtype may describe their symptoms as more intrusive and participate in ritualistic behaviour.

Subtype #3 - Sensory Subtype

Individuals with the sensory subtype will struggle with the sensations that come with the symptoms of vomiting (nausea, upset stomach, cold sweats), but also the feelings of vomit (feeling vomit come up in their throat and in their mouth).

Subtype #4 - Disgust

The fourth subtype is disgust. People who struggle with the disgust subtype will describe feeling disgusted when they are around vomiting stimuli. This is treated differently than anxiety as the disgust is processed in the insula rather than the amygdala. When it comes to managing with disgust accommodations are made to help the individual manage with the disgust. It's important to note that accommodations will not be processed as a safety behaviour (the safety behaviours maintain the fear), because the disgust is processed neurally in the insula.

How it’s Treated - Emetophobia

The goal of the therapy is to help improve self-efficacy and self-confidence. This is done by examining rigid beliefs one may have about vomiting and challenging harm-related thoughts. Focus is also attended to coping and how an individual can manage some of their feared thoughts around vomiting.

Therapy will also explore examining fears around the panic like sensations one feels before a vomiting episode or managing the actual episode of vomiting. Individuals with emetophobia may also become increasingly more sensitive to stressful situations where an upset stomach may occur and may interpret these sensations as threatening. This appraisal is what is challenged in therapy.

Meditation is Necessary!

I do believe that meditation is a necessary component of emtophobia treatment. Not only does it help with the attentional bias (attending to vomiting stimuli or situations where they could potentially be sick), but it also helps with the neural growth that may have occurred by repeated checking of the gut. When individuals perform checking behaviours to see if they are sick, they develop new neural growth in that area and it often influences how they feel when they are actually sick. Put simply when someone is actually sick with a stomach illness, people who perform repeated checks of their gut are likely to describe feeling more cramping and discomfort in their stomach than someone who doesn't repeatedly check their stomach (for instance someone who doesn't have emetophobia or IBS).

Cognitive Behavioural Therapy for OCD

This may sound odd given that emetophobia is not an OCD specific disorder. I am aware that emetophobia is considered a specific phobia in the Diagnostic and Statistical Manual, however, what I have noticed is that individuals with emetophobia are more likely to perform mental rituals. The mental rituals maintain the fear. Finding an OCD therapist is important when looking to manage your emetophobia. If you have a better understanding of the mental rituals you will likely be more successful in your recovery.

Similar to OCD therapy, your goal for emetophobia therapy is to shift your thinking that you can tolerate the experience (as you do other uncomfortable experiences related to the body) of vomiting. The other goal is wake up everyday expecting to vomit and knowing that you can manage.

Exposure with Response Prevention

Treatment for emetophobia requires exposing the sufferer to vomiting-related objects or situations. This may sound scary, but it’s done so with the guidance of the psychologist and the readiness of the patient. Motivation and client collaboration is key to success when working with exposure. The patient has full control and will only participate in activities that they feel ready to attempt. Remember you can’t do exposures unless all of the safety behaviours are removed. If the safety behaviours (both physical and mental) continue there will be no habituation.

You cannot see the emetophobia as a monster!

There is a popular book I use to help my emetophobia patients called, The Emetophobia Manual by Ken Goodman. I like his work and my patients have found success with it. But, there is only one issue I have with it which is chapter #6. In this chapter, he recommends that the reader begin to see the emetophobia as a monster and suggests that the reader talk back to it. This is not recommended. If you continue to meet the emetophobia thoughts with a negative emotion you will continue to process the thoughts as a threat and it will be processed as a safety behaviour. Lastly, if you are going to talk back to the emetophobia thoughts you are engaging with it and therefore performing a safety behaviour. The goal is to allow the thought to be there and to allow it to flow away as learned in the meditation. Once you let the thought pass, you continue with your day.

Do I need to vomit to get better?

No, vomiting is not required to perform exposures or to finish treatment. Most patients with emetophobia are more so concerned about the symptoms of vomiting and not the actual episode itself. In fact, most sufferers would describe relief after vomiting.