What is Emetophobia and How do We Treat it?

Is Emetophobia, the fear of vomiting, getting in the way of you living your life?

By Ferdinando Palumbo, MSW, LCSW

Disclaimer: This blog post will use language related to becoming ill and vomiting. People experiencing emetophobia may find seeing these words distressing. I firmly believe though that you can handle seeing these words and learning about emetophobia.

What is Emetophobia?

Emetophobia is a very fancy name for the fear of vomiting. Although most people find the experience of vomiting to be unpleasant and undesirable, for some people, this fear of throwing up rises to a level that disrupts their ability to live their day-to-day life. Dutch researchers Van Hout and Boukman (2012) found in a community sample that 8.8% of people experienced a problematic fear of vomiting that rose to diagnosable Emetophobia. Despite this condition being relatively common, I find that there are fewer therapists trained to treat emetophobia than one might expect. In my clinical practice in Northern NJ, I have found increases in clients seeking treatment specifically for Emetophobia. In this blog post, we’ll look at the impacts of emetophobia on people, a case study, and how we here at Northern NJ CBT help people with Emetophobia get back their lives.

How does Emetophobia impact sufferers?

Emetophobia can seriously impact the lives of people with this condition. Unfortunately, for most of us when we have a phobia, we often fall into what we exposure therapists call the “avoidance trap.” People with emetophobia often engage in various forms of avoidance. In my practice I commonly encounter emetophobic children, teens, and adults avoiding people, places, experiences, and even food in hopes of trying to reduce the probability of experiencing nausea or vomiting. Unfortunately, this only works for a short amount of time before people find themselves needing to engage in more avoidance to achieve the same level of relief. For more information on the avoidance trap and how exposure helps check out this blog post.

In addition to avoidance, some people suffering with emetophobia will also engage in ritual behavior in an effort to reduce the probability they will get sick. Oftentimes this is excessive handwashing, but can also be asking reassurance questions to loved ones, in children these rituals can even be less related like watching a favorite show with the aim of reducing the likelihood of getting sick. These serve the same function as outright avoidance and similarly “trap” people suffering from the fear of vomiting.

When we think of both the fear experience by people with Emetophobia and the avoidance that often accompanies the fear, it’s easy to see how this can become very disruptive to living a person’s life. In my practice, it’s not uncommon to encounter children and teens missing school and adults missing work or having challenges at home due to this strong fear. The good news is that we can successfully treat emetophobia and get back to the life we want!

Case Study

“Jeff” is a young adult with lifelong emetophobia. His doctor has informed him he is  approximately 20lbs underweight based on height and weight charts. He recalls even in early childhood being very afraid of vomiting after seeing peers get sick.  He avoids saying words associated with throwing up. His diet has gotten increasingly restrictive as he has become more worried about different types of food potentially leading to illness. In addition to significantly reducing the kinds of food he eats, he avoids eating to satiety due to concerns that being “full” could potentially lead him to vomiting. This has impacted his social and occupational life as it is hard for him to do lunch or dinner meetings due to his limited diet and abnormally small portions. He finds himself thinking almost nonstop about the possibility he could throw up and would like to have a life free of constant worry about becoming ill.

Treating Emetophobia

“Jeff” is a composite of the scores of patients I have worked with who are experiencing distress due to Emetophobia. In working with any of our clients going through struggles similar to Jeff, we would want to work on creating a hierarchy or menu where we would rate various avoided experiences on the level of distress associated with them then working on conquering each of these fears. The goal in well done exposure therapy is that the items on the list today that are 8s or 9s out of 10 in levels of distress will in the future be more like 5s and 6s out of ten as we work our way up the hierarchy.

This is an example of what an exposure hierarchy for emetophobia could look like:

·       Saying/Writing words associated with vomit (e.g., throwing up, puking, barf, etc.) 4/10

·       Writing a story about getting sick and imagining it 5/10

·       Eating an avoided food 6/10

·       Watching cartoon characters vomit 7/10

·       Going to an amusement park 8/10

·       Watching videos of people vomiting 9/10

In this example hierarchy, we would likely start Jeff with the least stressful exposure, which we have as saying and writing words associated with vomiting. We would repeat this until this became less distressing and Jeff would learn that he cannot only face avoided stimuli but also that this becomes less distressing each time.

We would then work on building up toward more challenging exposures as Jeff would develop a sense of mastery over his fears, each step along the way.

Where Therapy for Emetophobia Sometimes Goes Wrong

At Northern NJ CBT, we get many people experiencing emetophobia who have had previous bouts of unsuccessful treatment. Typically these other therapists are not specialized therapists with significant experience treating anxiety disorders. Although anxiety therapists can make mistakes as well, most of these unsuccessful attempts at treatment typically involve these mistakes:

·       Not using an evidence-based treatment for Emetophobia.

o   Unfortunately, very few therapists are properly trained in cognitive behavioral therapy methods for emetophobia. Instead they typically rely on treatments which have not been researched and have not been shown to be effective for the treatment of emetophobia.

·       Relying on talk therapy.

o   Insight oriented talk therapy may have some uses. However, trying to find some mythical “why” or “root cause” and discussing how emetophobia developed, will have very little bearing on how the emetophobia is being maintained. I like to use the example if someone wanted to quit smoking we wouldn’t look at why they stated smoking 16 years ago, we would want to focus on what that person is doing today to maintain their smoking problem.

·       Encouraging safety behaviors and avoidant coping.

o   It is not uncommon for therapists who are not anxiety disorder specialists to encourage avoidant coping. These well intentioned therapists are actually adding to the problem when they encourage clients to avoid triggers.

·       Relying on coping skills training as a standalone treatment.

o   Coping skills training meant to decrease emotional distress is treating the symptoms of anxiety rather than what is maintaining the fear—avoidant coping. At times the usage of coping skills can even increase problematic avoidance. Any therapy that treats emetophobia successfully will target avoidance and faulty reasoning that leads to emetophobia. For more thoughts on why I don’t generally like coping skill training for anxiety, please read this post.

Fortunately, we are able to help people get long lasting recovery through Cognitive Behavioral Therapy. This condition is very treatable with a proper treatment plan.

Mistakes Made Treating Emetophobia with CBT

Starting with the right treatment and an experienced emetophobia therapist is important. Even with a therapist using the we should also look at the errors Cognitive Behavioral Therapists make in treating emetophobia. These errors usually involve one of the following:

Starting with the right treatment and an experienced emetophobia therapist is important. We should also look at the errors Cognitive Behavioral Therapists make in treating emetophobia. These errors usually involve one of the following:

·       Improper pacing of exposure.

o   Therapists can do this in two directions, going too slow but also going too fast. When exposure is done too slowly can impede clients building confidence that they can handle more intense fears. Going through exposure too quickly though, can lead clients to want to discontinue therapy and convince them exposure therapy is difficult. We want to go at a steady pace building confidence and helping clients to fear their triggers less. I like to think of the moral from The Tortoise and the Hare “slow and steady wins the race.”

·       Exposures which don’t target the core fear.

o   When we engage in exposure therapy in we are trying to help the client learn specific things about their fears. We have to make sure though we are targeting what the client fears most so they can learn about overcoming their specific fear. If someone is afraid that they will get sick from a specific type of food, let’s say sushi, we would want to include that specific trigger as an exposure. Exposures to less feared foods may keep the person afraid of sushi because we weren’t specific enough in our exposures.

·       Not targeting and eliminating safety behaviors.

o   Safety behaviors, anything we do to reduce distress or prevent a negative outcome, also impede the learning process of exposure therapy. These safety behaviors end up convincing people that they cannot fully face their fears. An experienced exposure therapist will work with clients to identify what safety behaviors are impeding exposure therapy and slowly removing each of these until the person is facing their fears unassisted by any safety behavior.

·       Not doing post exposure processing.

o   This subtle addition to exposure therapy is important. You just faced something distressing, it’s important to discuss what happened and what was learned. Was the exposure unpleasant? Probably. Was it an unmitigated disaster? Probably not. It’s important to process the experience after exposure to really highlight what we learned abut facing fears.

·       Not getting clients to engage in exposure in between sessions.

o   In my first blog post ever I talked about the importance of completing exposures in between sessions. One of the reasons is, that we can become overly dependent on having the therapist present during exposures and become less confident in facing fears on our own. The more we can get out clients to face their fears in between sessions, the better these clients will do.

The most important takeaway is that certainly Emetophobia can be an impactful condition but with high quality Cognitive Behavioral Therapy, you can have lasting recovery and symptom relief. If you are in New Jersey and seeking treatment and would like a free 20 minute consultation call fill out this contact sheet and we will contact you as soon as possible.

If you are clinician seeking consultation or training related to emetophobia please feel free to reach out using the same contact form!