Emetophobia: Symptoms and Treatments that Require Continuous and Dedicated Effort by Patients
Emetophobia: A fear of vomiting that causes great stress for those who suffer from it.
DSM (Diagnostic and Statistical Manual of Mental Disorders): a manual using by mental health professionals in the United States.
SPOV: Specific phobia of vomiting.
Locus of Control: refers to the extent to which individuals believe they can control events affecting them.
Cognitive Behavior Therapy (CBT) - a type of psychotherapy in which negative patterns of thought about the self and the world are challenged in order to alter unwanted behavior patterns or treat mood disorders such as depression.
Eye Movement Desensitization and Reprocessing (EMDR) - an integrative psychotherapy approach that has been extensively researched and proven effective for the treatment of trauma. EMDR is a set of standardized protocols that incorporates elements from many different treatment approaches.
Definition and Criteria
Emetophobia is a fear of vomiting that can cause great stress for those who suffer from it. With the cause being somewhat unknown, some therapists strive to treat the disorder with Cognitive Behavior Therapy or other treatments that have shown promise for healing or relief. Which treatments are most effective and what are the future outcomes for sufferers will be investigated. Emetophobia can be an unbearable illness that deserves more research from the medical community.
To understand how devastating emetophobia, the fear of vomit, can be, one must understand the illness on a deeper level. According to Abhijeet Faye who leads a research team from Department of Psychiatry, N.K.P. Salve Institute of Medical Science and Lata Mangeshikar Hospital, “Emetophobic symptoms can be mental, emotional and physical. The anxiety and fear can go from mild feeling of apprehension to a full-blown panic attack. Emetophobia is implicated in social, educational and occupational impairment and it causes significant restrictions in leisure activities” (390). A sufferer may therefore feel just a little worried about seeing or experiencing vomit or they may be completely overwhelmed with an advanced panic attack that harms their ability to cope with life. When feeling this way, a sufferer of emetophobia may actually adapt their entire life to the disorder making every effort to feel better by avoiding situations and protecting themselves against experiencing vomit.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a manual of standard classification of mental disorders used by mental health professionals in the United States. The DSM-IV shows criteria for a specific phobia of vomiting (SPOV). Veale, Institute of Psychiatry, King’s College London, provides the DSM criteria which in summary identifies a person suffering SPOV:
- The individual has a persistent fear of vomiting and their fear is extreme and without logic.
- The individual, if exposed to a reminder of vomiting and incidents related to vomiting almost always suffers an anxiety response which can be severe such as an anxiety attack.
- The individual is very aware and recognizes that their fear of vomiting makes no sense.
- The individual will seek to avoid situations which trigger the phobia and this may include work and social situations (274).
This criteria assists mental health professionals in diagnosing the illness of emetophobia. Still utilizing the criteria does not necessarily explain what a patient is actually feeling or experiencing.
Fear of Losing Control - Internal Locus of Control
This illness can be unbearable and leaves a sufferer feeling a host of symptoms. Symptoms that sound more like physical ailments than mental. According to research by van Hout and Bouman, Department of Clinical and Developmental Psychology, University of Groningen, there were over 60% of participants who took an Internet survey on emetophobia and reported the following types of symptoms: racing heart, sweating, shaking, feeling like they couldn’t breathe, pain or pressure in chest, feeling dizzy or faint, feeling out of touch with reality like the world was a dream, body temperature changes and a fear that they might lose control (35). This variety of symptoms can leave a patient shaken and afraid. So afraid that life can feel out of control.
The fear of losing control is such a big factor among emetophobics that some therapists think this is an underlying reason for the disorder. According to Davidson, Boyles and Lauchlan, When it comes to Emetophobia, it is different than other anxiety and depressive disorders in that Emetophobics believe that they can control events that affect them. This is called an internal locus of control and it may keep them from getting well as it adds to the fear and anxiety (32). Therefore, the emetophobics believe that they can control events that affect them. They might think if I do this or don’t do this, maybe I will or will not vomit. For instance, they may avoid certain places or foods in an effort to control their fear. For instance, an emetophobic may avoid the hospital for fear of getting a sickness from the patients or they may avoid eating spaghetti because they once saw someone throw up after eating it. It is a very vulnerable state of mind.
Being female not only puts one at risk, but it poses a specific problem in the possibility of pregnancy and what can occur during pregnancy – morning sickness.
Who is Vulnerable to Emetophobia?
So what makes a person vulnerable to this disorder? What are some of the things that make a person susceptible to SPOV? Researchers have been taking a look at these very questions, “Studies suggest it commonly develops in childhood with a mean duration of about 25 years and occurs almost exclusively in women (for this reason I will refer to clients in the female gender). The gender differences may be reflected in the normal population – men may be more likely to view vomiting as a joke and even desire to vomit after heavy drinking” (273) Therefore, just being female puts you at a much higher risk for emetophobia. This appears to be based on how men and women view vomiting differently.
Besides a different view between the sexes, there are other gender-related issues to consider with this phobia. For instance, Lipstiz, et al. conducted research that showed 22% of female sufferers said they either prolonged getting pregnant or delayed it all together due to SPOV. Approximately 12% of participants noted that although they feared pregnancy, they did not let their condition affect their plans. Finally 6% said that their pregnancies had been difficult due to the nature of the illness (151). So being female not only puts one at risk, but it poses a specific problem in the possibility of pregnancy and what can occur during pregnancy – morning sickness. With morning sickness, women usually throw up and this is a well-known complication of pregnancy, therefore this fact does not go unnoticed by sufferers of emetophobia who are focused on their fear of vomiting or experiencing vomiting.
With research showing that the majority of sufferers are female, what other factors help to determine who will develop emetophobia? There may be other deciding factors for sufferers. Faye, et al. studied a case wherein symptoms, “Started with the remembrance of episode of acute appendicitis and research shows that people with emetophobia recall the memories of their own or others’ vomiting experiences from an earlier age and rate them as significantly distressing. The present case study also illustrated that exposure to distressing or otherwise aversive situation can lay down the groundwork for phobic conditions like emetophobia” (391). Therefore, traumatic past events of vomiting episodes can trigger the disorder. These may include the subject vomiting themselves or witnessing someone else vomiting. Either way, how is this trauma, in the form of emetophobia, best treated?
Treatment for Emetophobia
The trauma and symptoms of emetophobia are treated in a variety of ways, but it is essential to learn how to first control the anxiety that often comes with the disorder. Boschen and Tian report that, “A certain level of anxiety symptoms is seen as functional, while excessive or inadequate arousal levels impair performance” (817). One of the ways to bring relief from excessive anxiety that the researchers suggest is through relaxation training which may include controlled breathing training. These methods help reduce anxiety and help manage the patient’s fear and arousal. This may make the patient feel like they have some empowerment and control in copying with the anxiety (818). This treatment can then be used along with some other popular therapies to help the patient find relief from the anxiety that comes with SPOV.
Cognitive Behavior Therapy (CBT) to Treat Emetophobia
The most common form of treatment for SPOV is Cognitive Behavior Therapy (CBT). Cognitive Behavior Therapy may include different interventions. Boschen, Neumann and Waters from the School of Psychology and Griffith Institute of Health and Medical Research discuss cognitive restructuring as, “the primary vehicle by which perceptions of danger are addressed. Danger cognitions are, of course, addressed also through the acquisition of new information and experiential learning” (815). This restructuring takes the distressing thoughts and seeks to replace them. It is a redesigned way of thinking of a situation and therefore experiencing things differently.
One way that restructuring can work with a patient is by helping them to view vomiting differently. This is an effective way to help an emetophobic to rethink things. For instance, Veale says, “The therapist should normalize the experience of vomiting as being an adaptive process that increases chances of survival if she became ill. Information may be given about how vomiting is beneficial and prevents disease by getting rid of toxins. Thus the rat is the only animal that cannot vomit and one reason why rat poison is so effective” (279). Normalizing the experience of vomiting is one way to change the way a sufferer thinks of vomit and begins to see it as a good thing. If we couldn’t vomit, we might be holding on to things that are not good for our body.
Part of CBT is something called refraining. This involves a very courageous move on the behalf of the patient. “As part of treatment of anxiety disorders, an individual needs to refrain from the behaviors they usually use to relieve anxiety. When these anxiety reducing responses are inhibited, the usual pattern of negative reinforcement is circumvented. Furthermore the individual perception of their copying ability is strengthened” (815). Emetophobics have safety behaviors in place that they use to comfort themselves. Utilizing these behaviors actually inhibits the therapy process so sufferers must refrain from what they usually do when anxious.
To understand how utilizing certain safety behaviors inhibit a person getting better from SPOV, Buschen and Tian outlined a case study of 30 year old women. This woman, when shown specific things would begin to suffer gastrointestinal problem and would immediately become worried that she would vomit. She had become extremely jittery and cautious about her stomach issues and would seek reassurance from her husband that she wasn’t going to get ill. In reinforcing her, he was actually providing negative temporary fixes that were going against the grain of the therapy she was receiving (819). Therefore, in an effort to get well, this woman needed the cooperation of her husband and his agreement not to use temporarily reassurance. This reassurance was simply keeping her coping ability in a weakened state.
Finally, another CBT is called exposure therapy. This is simply what it says – gradually exposing the emetophobic to what they are most afraid of. One way to do this is by creating fake vomit. The recipe consists of, “Tinned rice, minestrone or chicken soup mix, Parmesan cheese, vinegar and sour milk” (284). “The guiding principle for graded exposure in vivo in SPOV is to choose both (a) internal cues of vomiting (e.g. past memories of vomiting, thoughts, images or sensations associated with vomiting, (b) external cues for vomiting that are being avoided or devised for the treatment programme (e.g. smell of vomit)” ( 282). Therefore, a patient is exposed to the fake vomit and graded on how the exposure makes the person feel. This continues until the feelings of anxiety gradually decrease over time.
Eye Movement Desensitization and Reprocessing (EMDR) to Treat Emetophobia
Another interesting form of therapy that deserves attention is Eye Movement Desensitization and Reprocessing (EMDR). This is a therapy used on individuals with Post Traumatic Stress Syndrome (PTSD). Research done by De Jongh shows that, (EMDR) is a treatment used on people with post traumatic stress-disorder or PTSD. Emetophobics often suffered from childhood and the onset of the disorder usually follows a stressful situation that involves vomiting or seeing others vomit. Therefore it was wondered if EMDR would be helpful in resolving stressful memories similar to those with PTSD especially the ones that were present at the start of the emetophobia condition (10). The therapy consists of resurfacing memories and utilizing rapid eye movement to help take away their traumatic affect. The therapy has proved effective in decreasing symptoms and relapse.
The exact treatment of EMDR is aimed at taking the most distressing of memories which could be at the root of emetophobia anxiety. These memories are recalled and the patient is asked to concentrate on the memories. While concentrating on the memory that is both distressing and vivid, the patient must also recognize how he or she feels and what false belief is behind that feeling. At the same time, a therapist then moves his or her fingers back and forth in front of the client and asks that client to track the movement, focusing on the fingers all the while also thinking about the distressing memory. This process is then rated on a scale of 10 to 0 depending on how the patient feels (11). In targeting these memories in this manner, the trauma can be reduced and, as in the case of 36 year old women, she had no relapse at her 3 year follow-up (10). EMDR is a treatment that should be considered for trauma-based anxiety in the treatment of emetophobia.
Medication to Treat Emetophobia
On final factor to consider in the treatment of emetophobics is patient willingness to seek help. According to research, some emetophobics are frightened of treatment. Some will not even bring up SPOV to their therapist and there were others who replied that they would not participate in treatment such as exposure therapy. Some participants would not take anti-anxiety medication for fear that the mediation itself would cause nausea leading to vomiting (152). It is interesting and challenging to treat an emetophobia given these finding as they fear the very things that might bring them relief from fear when it comes to treatment.
Relapse in Emetophobia Symptoms
In the struggle to find treatments for emetophobics, the situation of relapse cannot be ignored. Relapse means that a person becomes symptomatic again after a period of recovery. Research has proved that relapse occurs in anxiety disorder patients even though treatments are available. Between one- third and two –thirds of people treatment for an anxiety disorder will relapse after 8 years. The researchers offered 10 recommendations for clinical practice that may assist in reducing relapse rate in patients with anxiety disorders. Summarized, the recommendations are: Longer exposure sessions, increased number of sessions, shorter duration between sessions, encouraging the relinquishment of distractions, utilizing an assortment of fear cues, conducting exposure therapy in different environments, making sure exposure causes anxiety, assigning homework tasks, re-encounters with the feared phobia and cognitive restructuring (90). Relapse can be discouraging because it shows that no treatment is fail safe and permanent treatment, but with the recommendations, perhaps relapse can be avoided.
Experts agree that further research must be conducted in order to aid in finding underlying causes and more successful treatments for sufferers.
In conclusion, emetophobia can be devastating disorder for which the basis is only loosely known. Research shows that most sufferers are female which may have to do with the way men and women view vomiting. Also playing a part could be a traumatic past experience with vomiting as evidenced by research done that shows the EMDR has been helpful in reducing symptoms. Besides EMDR, health professionals have used a couple different treatments which prove to be somewhat successful and include, CBT and medications. But experts agree that further research must be conducted in order to aid in finding underlying causes and more successful treatments for sufferers whose whole life can be turned upside down by this phobia as they avoid certain situations, place, people and food in an effort to protect themselves from anxiety responses. Sufferers of emetophobia and family of sufferers should therefore consider finding and experimenting with the various treatments for the disorder to find relief. They shouldn’t stop there as more is needed to help find better cures and better understanding of this illness. They should be encouraged to participate in studies and research encouraging their therapists and doctors to do the same so that more attention and effort can be given to finding better and more effective treatments.
As a sufferer of SPOV (emetophobia), the following treatments have helped me most?
For an inside view of emetophobia, read the following article:
Boschen, Mark J., David L. Neumann, and Allison M. Waters. "Relapse of Successfully Treated Anxiety and Fear: Theoretical Issues and Recommendations for Clinical Practice." Australian and New Zealand Journal of Psychiatry 43.2 (2009): 89-100. Print.
Boschen, Mark J., and Tian P.s. Oei. "A Cognitive Behavioral Case Formulation Framework for Treatment Planning in Anxiety Disorders." Depression and Anxiety 25.10 (2008): 811-823. Print.
Davidson, Angela L., Christopher Boyle, and Fraser Lauchlan. "Scared to Lose Control? General and Health Locus of Control in Females with a Phobia of Vomiting." Journal of Clinical Psychology 64.1 (2008): 30-39. Print.
Faye, Abhijeetd, Sushil Gawande, Rahul Tadke, Vivekc Kirpekar, and Sudhirh Bhave. "Emetophobia: A Fear of Vomiting." Indian Journal Of Psychiatry 55.4 (2013): 391. Print.
Hout, Wiljo J. P. J., and Theo K. Bouman. "Clinical Features, Prevalence and Psychiatric Complaints in Subjects with Fear of Vomiting." Clinical Psychology & Psychotherapy 19 (2011): 531-539 Print.
Jongh, Ad De. "Treatment of a Woman with Emetophobia: a Trauma Focused Approach." Mental Illness 4.1 (2012): 10-14. Print.
Lipsitz, Joshua D., Abby J. Fyer, Anthea Paterniti, and Donald F. Klein. "Emetophobia: Preliminary Results of an Internet Survey." Depression and Anxiety 14.2 (2001): 149-152. Print.
Veale, David. "Cognitive Behaviour Therapy for a Specific Phobia of Vomiting." The Cognitive Behaviour Therapist 2.04 (2009): 272. Print.