An Emetophobia Researcher’s Review of the Text: Gag Reflections by Dara Lovitz and David Yusko

I write this fully recognizing that it's not easy being an OCD therapist. When new information comes up or people attempt to try new things, it is often met with resistance from those in our community. I often feel insecure at times presenting some of my own work, given some of the criticism that some of my colleagues have received from other OCD and anxiety therapists. A few weeks ago I offered to write emetophobia material for the ADAA blog and was told they are not of need of that material and than ghosted me when I pressed why (I won’t mention any names). We need to do better. It's unfortunately not a safe space to share and for us to grow as a profession, but if we want to succeed in learning more about particularly rare disorders, we need to continue to put forth new material and be tolerant of it being challenged. With that being said, I appreciate Dara Lovitz and David Yusko's text, the Gag Reflections. I think there are parts of the text that are quite excellent, while other parts need work. Here is my review:

Dara Lovitz did an excellent job of describing her treatment journey. She really provides her readers with hope and inspiration. I hope she continues to speak out about emetophobia and promote getting support for the condition. However, there is something that I do believe that Dara and Yusko (her psychologist) are missing. I would urge readers to view Dara's case as a case study rather than a success story. There is much evidence in the text that suggests that Dara is actually not experiencing difficulties with classic emetophobia, but actually vasovagal syncope. I was able to pick this up during her description of her symptoms when she went to the Eagles football game and she described feeling dizzy. This was further supported by her description of frequent fainting episodes. This is why important to rule out any physical health concerns before treating the psychological concern. In this instance, the case conceptualization changes to accommodate her vasovagal symptoms. She described having to do the exposure sitting in the crowded subway car while dizzy, but there was more evidence to suggest that this was her medical condition that needed to be tended to and not a situation where she should have been doing exposure. Quite commonly, many individuals present with emetophobia but often have prevasovagul syncope, vasovagal syncope, or POTS. A clinician should rule these out before proceeding with treatment treatment.

I like exposure therapy and it makes sense to me. But the book misses the mark when it comes to the importance of understanding the cognitive work that NEEDS to be done when working with emetophobia patients. A few weeks back, I presented my findings on specific subtypes that people with emetophobia experience difficulties with. In the case of Dara, she was doing the wrong exposures. There is evidence throughout the text that she was experiencing difficulties with the social subtype and sensory subtype. Throughout the text she was able to work on the sensory subtype exposures, which only helped her manage some of her symptoms. This means that she is likely to still experience difficulties in the future because the exposures should have been tailored to her true fear which is being judged and embrassed when throwing up. For her to truly be better from her emetophobia she would have to really devote time to understanding how she could do exposures to address the social subtype, which could include pretending to vomit in front of others (peers and strangers). The subtypes I outlined, need to be observed, evaluated, and built within the exposures. Dara would also have to observe the extensions of her core fear and how they are influencing other areas of her life. Because the social subtype is influenced by being judged by others, she may be apprehensive about being judged by others in other areas of her life- those other areas need to be evaluated and she would have to build exposures around those issues as well (for instance, she may be afraid to public speak - this too would have to be managed with the exposure work). I reference this type of work in my blog article titled Extensions of Core Beliefs.

The book indicates that anxiety usually lasts 10 mins, and it's better to stay in the anxiety-provoking situation until it goes away.

I don't believe that anxiety lasts 10 minutes. I think that we need to move away from that idea and promote that it may last an unknown amount of time, and that's ok. If the patient continues to look at that time they may process the anxiety symptoms themselves as something to be fearful of and this may only further perpetuate the anxiety later on.

Dara mentions a few techniques to help manage a vomiting episode. It is best not to do these things. She mentions using laughter to 'diffuse' the anxiety and practicing self-regulation when confronting the anxiety—DO NOT DO THESE. These will all be processed as safety behaviours. Lastly, do not distract yourself during an exposure—this, too, is a safety behaviour.

I really like Chapter #5 and Chapter #6. I would be recommending these chapters to my clients. This was fantastically written. There is one part that I do differently than Yusko. I don't believe in leaving exposures early. I have my patients stay with the exposure UNTIL the anxiety is down to zero. This may take all day, but to me, this is how it's supposed to be done. In my experience, any exit (even if it's at a 1 or 2 out of 10) is likely to be processed as a safety behaviour. When it comes to exposure to contaminated items, I don't believe in having the client touch an item and having them sit in discomfort. I have them get a cloth rub it on the contaminated item and get them to contaminate their home and workspace by rubbing that cloth on everything. Yusko's description offers an escape that will lead to unsuccessful habituation. True exposures do not have an escape when it comes to contamination. I professionaly don't believe in titrating the exposures (watching a vomit video without the sound). I may try it with some patients in the future, but I never needed too use it.

What I have learned from the text:

I really like how Dara used self-talk to help her through the situation. She doesn't use self-talk to reduce anxiety (which will be processed as a safety behaviour); she uses it to motivate herself through exposure. Great piece of advice.

The discussions about the anxiety irritability connection are on point. Many people with anxiety-related issues, at times, experience difficulties with irritability. Dara does a wonderful job explaining the connection using her own personal narrative. I will be sharing this with my own patient group.

I really like how Yusko talked about disgust and how it is something that we just have to tolerate. I like using accommodations for disgust when working with my patient group. This may mean closing your eyes, flushing the toilet, or vomiting in a bag or t-shirt to remove the stimuli. This, to me, isn't a safety behaviour but helps make the experience more tolerable.

Dave and Dara deserve praise for a good effort. Thank you for this resource. Hopefully my suggestions are worth something.