Day-to-day life can be a living nightmare for an emetophobe. Chances are you have met one and didn’t even know it. Peppermints, antiemetics, antacids and antiseptics are their standard weapons of choice in the often lifelong and epic battle against, and extreme at-all-costs avoidance of, their mortal enemy – vomit.

A surprisingly common ‘side-effect’ shared by emetophobes is jumping out of a moving vehicle, as described by one US-based emetophobia sufferer:

“I frantically unlocked the door and jumped out of the moving car and took off down the street, away from my barfing brother.”

Despite early evidence suggesting that emetophobia could be one of the most common yet highly debilitating phobias on the planet, perhaps the unglamorous nature of a morbid fear of the technicolored yawn has left it in the shadows of well-recognized and researched yet less common phobias such as spider phobia (arachnophobia) or the fear of heights (acrophobia). It isn’t likely that the blockbuster hit, Emetophobia, will be gracing the silverscreen anytime soon.

This lack of knowledge and research on emetophobia is quit shocking to say the least. Particularly shocking when considering it often persists as a chronic, unyielding condition giving sufferers little respite throughout their entire lifetimes, commonly resulting in potentially deadly, highly intrusive and severely debilitating life limitations.

Below is a summary of the latest published research about what emetophobia is, the symptoms, the psychology, and most importantly, the best help and known treatments for curing emetophobia:

• What is emetophobia?
• How common is emetophobia?
• Emetophobia psychology: how does someone become an emetophobe?
• Emetophobia symptoms & problems
• Emetophobia test
• Emetophobia treatments
• Emetophobia help & support

What is emetophobia?

The broad emetophobia definition is, the fear of vomiting. The main focus of an emetophobe’s fears can differ between individuals, including a fear of feeling nauseous, seeing vomit or other people vomiting, and a fear of vomiting themselves, especially in public.

How common is emetophobia?

It is currently near impossible to say with certainty how common emetophobia is. A German study calculated a point prevalence rate of just 0.1% in 2007, although a recent study in 2011 on a Dutch community sample produced an emetophobia rate of 8.8% with a female-to-male ratio of 4:1 — a female gender bias also found for other anxiety disorders.

Considering this initial rate of prevalence in the Dutch sample is equal to and even exceeds published estimates of the percentage of people living with any phobia (4-9%), further research into prevalence rates is warranted, stat!

Emetophobia psychology: how does someone get emetophobia?

Both experience in the lab and in the doctor’s office suggests that the majority of people develop emetophobia from adverse events occurring between the ages of 10 and 18, although emetophobia can appear at any age. It rarely persists for a few relatively short years. Generally, it sticks around for 20 years or more, often lasting an entire lifetime.

The predominant model for emetophobia is based on results from a self-report questionnaire and is in line with associative theories of phobia development. The available data suggests that an autobiographical memory of a vomit-related incident from the past can lose its time perspective and context, and is then indomitably reactivated in the present when witnessing vomit-related cues.

One case series showed that children developed emetophobia shortly after a stomach virus or medical procedure that caused them to vomit, while another case involved a boy who had witnessed his grandfather vomit while dying.

A study scheduled for publication in 2016 has begun to dig deeper into the psychology behind emetophobia, pinpointing the emotion of disgust as the main driver of the irrational thought processes involved in both the development and persistence of emetophobia. Put simply, experiencing strong feelings of disgust are illogically equated to there being a high level of danger to one’s health.

Emetophobia symptoms and problems

Emetophobic symptoms can be mental, emotional and physical, with the vomit-related anxiety and fear ranging from mild feelings of apprehension to a full-blown panic attack. As such, emetophobia is implicated in social, educational and occupational impairment, and is known to cause significant restrictions to leisure activities.

The main problem with emetophobia is the avoidance-behaviors that can pervade almost all facets of life, as has been shown in both larger scale assessments and individual case reports. This can include avoiding school or work, public toilets, television programs and movies, sick or dying family and friends, animals that vomit and all social situations and all modes of transport, as well as alcohol and food restrictions, the worst of which being complete starvation.

It even caused approximately half of the women in an online survey to delay or even completely avoid pregnancy specifically to boycott the near inevitable nauseating experience of morning sickness.

Another common problem is that due to associative learning, vomiting can become associated with a completely non-vomit related event or object. For example, having had the emetophobia triggering event occur at a pet store, may result in pet stores, or the smell of pets, also becoming an emetophobia trigger and being similarly avoided.

There are also reports in the literature that emetophobics are misdiagnosed as presenting with many other disorders due to a large overlap in symptoms, including panic disorder with agoraphobia, social phobia, anorexia nervosa, obsessive-compulsive disorder, depression and irritable bowel syndrome.

Emetophobia test

A reliable and valid measure for the assessment of emetophobia was only just published in 2013, known as the emetophobia questionnaire (EmetQ-13), which is available online via Anxiety UK.

Best emetophobia treatments

Most emotophobia treatment studies published thus far have been case studies, with no randomized controlled trials on emetophobia treatments to date – the literature is only really just beginning to develop in the past couple of years.

Of course, as a specific phobia, some sufferers may find success with popular phobia treatments such as cognitive behavioural therapy and exposure therapy, along with relaxation techniques or meditation. However, among the long list of specific phobias, it has been reported that clinicians generally regard emetophobia as challenging to treat because of high drop out and/or a poor response to treatment.

Nonetheless, here are some findings specific to emetophobia that could be of benefit:

• Exposure therapy: Essentially, conventional graduated exposure therapy is a form of CBT where a person is gradually exposed to increasingly more fear inducing situations and/or objects, learning to become less sensitive over time.

  One case study involved creating a fear hierarchy with the therapist to help guide the client’s individualized treatment through to completion, where the first session started with watching college humor vomiting videos on the computer, to more distressing vomiting videos. The highest rated stimulus on the hierarchy, the end goal, was the client forcing herself to vomit.

  On top of exposure-based homework, the client and therapist on goals for the minimizing of safety behaviors.

  Maintenance of these two main aspects of exposure therapy resulted in elimination of avoidance of feared situations and a reduction in the client’s hypervigilance to internal physiological feelings that had been associated with catastrophic fear and distress. Most importantly these gains maintained at a three-year follow-up.

  Both therapists and the client agreed that having the client physically vomit, as opposed to just imagining herself vomit, or seeing others vomit, was an essential component for her treatment.

  It is important to note that some emetophobic children have been reported as being unresponsive to conventional graduated exposure therapy. One case study overcame this unresponsiveness by counterconditioning anxiety responses to vomit-related cues by using competence imagery (imagining dealing with a trigger-related situation well) during progression through the gradual exposure therapy fear hierarchy, instead of using physical relaxation responses (patients practice tensing and relaxing different parts of the body until the patient reaches a state of serenity).

• CBT courses: Exposure therapy can be used stand alone, or in conjunction with other aspects of CBT, which is considered to be generally the most effective treatment across all specific phobias.

  In 2009, a CBT-based emetophobia treatment case study was published. The three main strategies included psychoeducation about anxiety symptoms, exposure in imagination and role-play, graduated exposure to feared situations, symptom induction exercises and dropping of safety-seeking behaviors. Despite the subject’s extreme fear of vomiting maxing out fear measurement scales before beginning therapy, by the 8th session, improvements included the ability to expose herself to previously feared situations and physical symptoms resulting in either no anxiety or minimal anxiety.

  One recently assessed program is Thrive, a CBT-based training programme designed to help sufferers with a wide range of psychological disorders, specifically providing emetophobic clients with an understanding of how their unhelpful beliefs and thinking styles were contributing to their phobia, as well as helping them to gradually change these ways of thinking.

  After finishing the programme, the majority (89%, 55 out of 62 participants) rated their symptoms as having little to no impact on their lives. The remaining 7 participants (11%) rated them as having a modest impact. This was also in line with the statistically significant improvements as determined by the therapist completing the Emetophobia Severity Scale, however this scale needs further research in order explore reliability and viability. A more rigorous study is required to add weight to these superbly promising results.

• Hypnotherapy: Two case studies that require updating and further research report curing patients of emetophobia using hypnotherapy, one from the late 70s, and the other from the 90s. In the 1994 case, a 44 year old woman was treated with hypnotherapy using the affect bridge technique to identify relevant traumatic childhood memories. During imagination under hypnosis, an ‘adult version’ of the client comforted the ‘child version’ of the client, which reportedly led to resolving the phobia.

Emetophobia help & support

Additionally, emetophobia help forums and societies may offer further support and advice:

• Emetophobia Resource– A resource to help therapists to treat emetophobia, or for emetophobia sufferers to help themselves desensitize to vomit.
• Emetophobia Help – Created by the same CBT and Skype-based emetophobia therapist as Emetophobia Resource, Anna Christie, this website is more suited to emetophobia sufferers and in helping them find an evidence-based therapist.
• International Emetophobia Society – The Web’s Largest Meeting Place and Forum for People With Emetophobia

References

Becker ES, Rinck M, Türke V, Kause P, Goodwin R, Neumer S, & Margraf J (2007). Epidemiology of specific phobia subtypes: findings from the Dresden Mental Health Study. European psychiatry : the journal of the Association of European Psychiatrists, 22 (2), 69-74 PMID: 17157482

Boschen, M., Veale, D., Ellison, N., & Reddell, T. (2013). The emetophobia questionnaire (EmetQ-13): Psychometric validation of a measure of specific phobia of vomiting (emetophobia) Journal of Anxiety Disorders, 27 (7), 670-677 DOI: 10.1016/j.janxdis.2013.08.004

Faye, A., Gawande, S., Tadke, R., Kirpekar, V., & Bhave, S. (2013). Emetophobia: A fear of vomiting Indian Journal of Psychiatry, 55 (4) DOI: 10.4103/0019-5545.120556

Hunter, P., & Antony, M. (2009). Cognitive-Behavioral Treatment of Emetophobia: The Role of Interoceptive Exposure Cognitive and Behavioral Practice, 16 (1), 84-91 DOI: 10.1016/j.cbpra.2008.08.002

Klonoff, E., Knell, S., & Janata, J. (2009). Fear of nausea and vomiting: The interaction among psychosocial stressors, development transitions, and adventitious reinforcement Journal of Clinical Child Psychology, 13 (3), 263-267 DOI: 10.1080/15374418409533200

Lipsitz JD, Fyer AJ, Paterniti A, & Klein DF (2001). Emetophobia: preliminary results of an internet survey. Depression and anxiety, 14 (2), 149-52 PMID: 11668669

Maack DJ, Deacon BJ, & Zhao M (2013). Exposure therapy for emetophobia: a case study with three-year follow-up. Journal of anxiety disorders, 27 (5), 527-34 PMID: 23973742

Moran DJ, & O’Brien RM (2005). Competence imagery: a case study treating emetophobia. Psychological reports, 96 (3 Pt 1), 635-6 PMID: 16050615

Muris P, Merckelbach H, de Jong P, & Ollendick TH (2002). The etiology of specific fears and phobias in children: a critique of the non-associative account. Behaviour research and therapy, 40 (2), 185-95 PMID: 11814182

Sykes M, Boschen MJ, & Conlon EG (2015). Comorbidity in Emetophobia (Specific Phobia of Vomiting). Clinical psychology & psychotherapy PMID: 26017849

van Hout WJ, & Bouman TK (2012). Clinical features, prevalence and psychiatric complaints in subjects with fear of vomiting. Clinical psychology & psychotherapy, 19 (6), 531-9 PMID: 21695748

Veale, D. (2009). Cognitive behaviour therapy for a specific phobia of vomiting The Cognitive Behaviour Therapist, 2 (04) DOI: 10.1017/S1754470X09990080

Veale, D., Murphy, P., Ellison, N., Kanakam, N., & Costa, A. (2013). Autobiographical memories of vomiting in people with a specific phobia of vomiting (emetophobia) Journal of Behavior Therapy and Experimental Psychiatry, 44 (1), 14-20 DOI: 10.1016/j.jbtep.2012.06.002

Verwoerd, J., van Hout, W., & de Jong, P. (2016). Disgust- and anxiety-based emotional reasoning in non-clinical fear of vomiting Journal of Behavior Therapy and Experimental Psychiatry, 50, 83-89 DOI: 10.1016/j.jbtep.2015.05.009

Image via Piotr Marcinski / Shutterstock.