Sick of Being Afraid of Being Sick? Time To Treat Your Emetophobia!

Vomiting.  Hurling.  Puking.  Retching.  Tossing Your Cookies.  Losing Your Lunch.  Talking To Ralph On The Big White Telephone.  Blowing Chunks.  And the list goes on.

If simply reading these words causes you significant discomfort, and you are feeling a strong urge to stop reading, then you should probably keep reading.

It may be hard to imagine that just the thought of experiencing such a ubiquitous and necessary human phenomena as vomiting could become so terrifying for so many.  Alas, for about 0.1% of the population (humans only, of course; most animals are spared from anxiety due to their lack of a cerebral cortex), this is a great and powerful source of almost continuous distress.  

At lower levels of severity or impairment, Emetophobia, the fear of vomiting, in self or others, and often both, afflicts between 3 and 9 percent of humans, with females cornering the market with 4 times the prevalence of men.

Although sufferers of more common phobias, such as as fear of injections, spiders, snakes, heights and public speaking, can, with effort, typically skirt around and avoid the object(s) of their phobia (often at more modest behavioral and psychological cost), individuals suffering from Emetophobia have a much harder time doing so as the focus of their anxiety actually resides within them.  Wherever you go, there you are.  This is somewhat reminiscent of the famous horror film line, "the call is coming from inside your house!"  For Emetophobics, a vast array of otherwise normal physiological processes can trigger the fear that emesis may be approaching: queasiness, fullness, lightheadedness, gastrointestinal upset (or even just "gurgling), headache, pregnancy, constipation, fatigue, sweating, or physical exertion. 

Owing to the power of negative reinforcement (wherein any behavior that leads to the avoidance or cessation of an aversive stimulus [anxiety] will be repeated), then, any activity that might trigger any of these sensations will also come to be avoided, and these pathways of avoidance behavior will persist, strengthen and generalize across time.  Eating and drinking behavior is closely monitored, social plans must be timed and arranged carefully so as to prepare for and work around the possibility of getting sick, and virtually any physiological sensation must undergo thorough risk assessment and scrutiny (which, paradoxically, typically strengthens the magnitude of the sensation and the associated worry).  Safety behaviors, such as keeping anti-nausea medications on hand, staying away from anyone who might have the stomach flu, and refraining from eating a wide variety of potentially stomach-upsetting foods, typically then proliferate.

As you may now understand, these patterns of sensation, thought, feeling and behavior become deeply ingrained over time (because, in the mind of the sufferer, they are all necessary and at least moderately successful in warding off the anxiety about vomiting).  Unfortunately, in addition to yielding an ever restrictive repertoire of behavior, the awareness of one's avoidance leads to self-criticism, shame, lack of confidence and depression.  Imagine being unable to provide emotional or medical support to a child or loved one who is ill because you fear the possibility of their vomiting (which may itself be the focus of your Emetophobia), and the possibility that you will "catch" what they have or simply vomit due to the upsetting exposure. 

Individuals with Emetophobia typically do also have a far greater fear of vomiting around others than by themselves.  They may see this as a repulsive, disgusting, wholly unacceptable and game-changing behavior in the context of interpersonal relationships, wherein they may fear harsh judgments from others and even total rejection or abandonment.  Their acceptance of themselves is also typically just as limited and conditional (I'm loveable if I don't vomit, and unlovable if I do).  For sure, a tragic and painful set of struggles with which to be saddled.

Finally, in addition to strengthening the fear of vomiting, avoidance behaviors also prevent the afflicted individual from actually learning to safely experience and cope with this evolutionarily correct behavior (we vomit in an effort to expel noxious material that may be more harmful to us if retained).  In fact, most individuals with Emetophobia will tell you that they have not actually vomited in quite a long time, if ever.  This depends on the patient's age of course, but I commonly hear patients tell me that they have not thrown up in between 5 and 20 years. 

So, what causes this condition to develop?  Several theories abound, but agreement exists in the view that onset stems from several intersecting factors.  First, there may be a predisposition to what is called "interoceptive sensitivity," which is an unusual degree of attentiveness to, and concern about, internal physiological changes, however slight they may be.  Second, there is typically an event or series of life events which do actually involve a somewhat traumatic experience related to illness involving vomiting.  Childhood medical problems in self or close others are commonly reported.  Third, the intersection of these first two factors have then been associated with feelings of terror, anxiety, possible or actual loss, separation or rejection, and of a very negative sense of loss of self-control.  Thus, a process akin to classical conditioning takes place, wherein a previously neutral stimulus, i.e., vomiting, is unintentionally paired with an extremely negative stimulus (acute anxiety or other perceived threat) and the neutral stimulus is thereafter able, on its own, to invoke the aversive emotional response.  This process is almost always implicated in the etiology of all phobias.  Finally, for the condition to really take flight, obsessive worry and behavioral avoidance must be enacted and repeated.  It is virtually impossible to be phobic about that which you fully accept and allow.

To clarify, nobody ENJOYS vomiting, and we usually recall episodes of such sickness with rather negative associations.  Most people, however, simply accept the necessity of this unpleasant experience and are thankful that their bodies know how to "take out the trash."  The relationship between the Emetophobic and the idea of vomiting is a different animal altogether.

Okay, let's discuss the treatment of Emetophobia.  The great news is that, as is the case with most impairing (and even crippling) psychological and behavioral manifestations of anxiety, effective treatment IS available for Emetophobia.  Empirical data are sparse, unfortunately, mostly owing to the rarity of the full-blown condition in clinical populations.  However, I have in my practice seen at least high moderate symptom reduction in most treatment adherent individuals across approximately 12 to 24 sessions utilizing a primarily cognitive-behavioral approach.

Treatment for this condition is fairly straightforward.  Patient adherence and motivation are key, and often difficult to elicit, however, because successful treatment requires the affected individual to at least temporarily relinquish their safety and avoidance behaviors.  So, yes, successful treatment of this phobia, as in all others, requires the patient to face the feared possibility of the feared outcome (vomiting) without any protection or insurance policy against it occurring.  I call this, "Facing The Monster."

The primary intervention is, therefore, Exposure Therapy.  This requires the patient and therapist to collaboratively identify all of the feared situations that the patient has in the past avoided, and for the patient to then actually seek these situations out and be exposed to them.  Response prevention, which simply means refraining from safety or avoidance behaviors before during or after the exposures, is also required and necessitates an idenfication of all overt or stealth techniques the patient has been using to minimze or avoid the risk of full exposure.  For example, a patient may be accustomed to coping with their fear of vomiting when out to dinner with friends by eating an extremely minimal amount of "safe" food, or by keeping anti-nausea medication on hand.  In the exposure scenario, the patient would be encouraged to eat a significant amount (of potentially risky foods versus bland ones), and to toss their Compazine in the trash.  A patient who refrained from eating for two hours in advance of having sex with his partner was instructed to have sex on a full stomach.  Finally, as alcohol intake is usually self-restricted by individuals who fear vomiting, they are often asked to increase their intake, especially when in social situations.  Exposures may also include the viewing of video clips or images involving vomiting.  The patient is required to observe and cope with any resulting outcome of their exposures, and to not use distraction, dissociation, or relaxation techniques during actual exposures.

Over time, as exposures to more and more potentially distress-inducing stimuli continue (and are not contaminated by safety behaviors), "habituation" occurs; in other words, the individual stops fighting against what they fear, comes to see that the actual results are tolerable, the fear is increasingly "lived with," and it therefore becomes increasingly irrelevant and unimportant.  It is easy for our brain to believe something is dangerous when it sees us doing everything possible to avoid that stimulus, and it is all but impossible for our brain to maintain these emotional and cognitive reactions in regard to something we appear to be facing with greater frequency, ease and willingness.  Progress is measured and tracked via "subjective units of discomfort," or SUDS (a 0 to 100 scale), in the context of exposures, and is subjectively rated by the patient across time.

In addition, cognitive work can be helpful in bringing more balance and accuracy to the patient's beliefs about vomiting and it's impact on one's mood and relationships with others, thereby reducing bias and distortion.  Developmental investigation is also often useful in helping the individual to understand the unfortunate experiences that led them to experience their fearful reactions to vomiting (and often to rejection, criticism or abandonment) in the first place.  This understanding can promote compassion and acceptance for the self, which is good medicine for any problem we face as humans.  Also, in-session "inductions" may be conducted wherein the patient is guided to perform behaviors designed to trigger anxiety about vomiting (having the individual hyperventilate or spin around in a chair until they become dizzy).  These interventions can be very useful in the hands of a skilled therapist and a willing patient.  Although I have never personally used this particular variant, one successful research study had patients consume a solution containing increasing amounts of syrup of ipecac (designed to induce vomiting), and paired this with other techniques described above.

I offer this description of treatment to promote understanding of what the most empirically effective approach involves.  I am not describing these methods as a "how to" manual, and I would encourage any afflicted individual to undertake such a course of treatment only in collaboration with a well-qualified mental health practitioner.  Sure, you can safely begin to educate yourself about the condition and guide yourself through some aspects of treatment; however, erroneous use of these techniques can lead to a worsening of the condition and a strengthening of avoidance, thus increasing the effort required to make improvement in subsequent therapist-guided efforts. 

If you are seeking a qualified therapist to help you with this condition, please ensure that you identify one with significant training in cognitive-behavioral therapy, and who has successfully worked with other patients with this condition.  The proper application of these methods is not for beginners, the condition is not expected to improve significantly with basic supportive counseling, and a primary treatment strategy solely involving medication is also not recommended.  Although psychotropic medication may be helpful in reducing symptoms, especially early on in treatment, it is not the gold standard as a standalone.  Further, given the presence of interoceptive sensitivity and the fear of physiological changes, the introduction of such medications can further complicate the patient's condition.

If you wish to read more about the effective treatment of phobias, including Emetophobia, it is recommended that you obtain the following resource: "Mastery of Your Fears and Phobias" by David Barlow (available at http://tinyurl.com/k5o8fck).

I sincerely thank you, Dear Reader, for your important question, and I hope that this information has been of some use to you.  I wish you courage and peace as you pursue recovery, and hope also that this condition becomes less and less an obstacle for you and your partner as you consider growing your family.  Feel free to address further questions to me on this topic, and to keep me posted about your progress.

Sincerely,

Richard E. Schultz, Ph.D.

BTW, feel free to read more about my approach and practice (www.drschultz.org), on my blog (www.mindset.mobi), and by following me on Twitter (@mindsetdoc).