Cognitive Behavior Therapy for Emetophobia – Fear of Vomiting

What is Emetophobia/Fear of Vomiting?

Emetophobia is an extreme fear of vomiting that interferes with daily life functioning. Estimates of its prevalence range from 1.7% to 3.1% for males and from 6% to 7% for females. While the fear of vomiting is quite common, it is one of the least studied phobias. Emetophobia often has a childhood onset following traumatic experiences of vomiting or seeing others vomit and follows a chronic course that worsens with age in the absence of treatment. Safety-seeking and avoidance behaviors (e.g., checking food expiration dates, avoiding alcohol, avoiding poultry and seafood, and choosing not to have children) are common among people with emetophobia.

Emetophobia may have symptoms that overlap with panic disorder, OCD, and social anxiety disorder. For example, individuals with emetophobia may be fearful that they will embarrass themselves or that others will evaluate them negatively if they vomit in public. A preoccupation with one’s gastrointestinal state and checking food ingredients may be observed in both emetophobia and OCD. Symptoms of panic attacks in specific phobias and panic disorder are often identical.

Symptoms of Emetophobia/Fear of Vomiting

• Food-related avoidance behaviors, such as restricted and/or slower food and fluid intake, avoidance of day-old and older foods, avoidance of specific foods and beverages, avoidance of eating out, and avoidance of eating with others.
• Other avoidance and safety behaviors, such as avoiding hot temperatures due to fear that being flushed or sweating may increase the risk of vomiting, being near people who are ill or having a package of gum available at all times in case you begin to experience a taste that might result in vomiting.
• Occupational consequences related to the fear of vomiting. For example, avoiding the medical field due to fear of being exposed to illness that could result in vomiting.
• Social consequences related to the fear of vomiting such as difficulty enjoying social events due to the avoidance of eating and drinking anything that could lead to vomiting.
• Low body weight due to reduced food intake related to the fear of vomiting.

Cognitive Behavioral Model of Emetophobia/Fear of Vomiting

You may wonder why you have developed a fear of vomiting. One way people develop phobias is through traumatic conditioning, or the association of a negative event with a previously neutral object or situation. Some other predisposing factors include physiological or genetic factors, general anxiety vulnerability and somatization vulnerability (a tendency to express anxiety through somatic symptoms such as ‘‘butterflies’’).

Sensitivity to internal bodily sensations or “triggers” are critical to the anxiety experience of many people who suffer from emetophobia. When people with somatization vulnerability experience situations in which gastrointestinal symptoms occur, they tend to interpret these as signals of an imminent danger of vomiting. This misappraisal of bodily sensations contributes to increased stress, which is in turn accompanied by additional bodily sensations, resulting in a feedback loop. In addition, after experiencing panic attacks, a period of worry and a state of heightened sensitivity to interoceptive cues is likely to occur, resulting in a feedback loop of recurrent anxiety symptoms. Some additional ways that phobias are maintained:

• Avoidance behavior that prevents correction of anxious misconceptions about feared situations,
• Avoidance or escape that brings relief and reinforces avoidance behavior; and
• Over-reliance on safety signals (objects or people that individuals rely on to help them cope with a feared situation).

Cognitive Behavior Therapy for Emetophobia/Fear of Vomiting

Cognitive behavior therapy, and specifically exposure therapy and cognitive restructuring, is the gold standard for the treatment of anxiety and phobias. In order to overcome a fear of vomiting, you must be willing to face the fear directly through exposure. Exposure involves experiencing the sensations associated with vomiting and situations that trigger your fear of vomiting, and not necessarily the experience of vomiting itself.

Interoceptive exposure involves the induction of physiological symptoms and bodily sensations that mimic anxiety. Some examples of interoceptive exposures include hyperventilating for 60 seconds, spinning around in a chair or circle, going on swings, wearing a sweater that is too warm for 30 minutes, and reading in a moving vehicle.

Situational exposures involve repeated exposure to the sensation of nausea or to several perceived triggers of vomiting (e.g., avoided foods) as well as eliminating safety behaviors. Some examples of situational exposures are eating 2-day-old leftovers, staging an imaginal experience of vomiting into the toilet, leaving gum at home on a high-anxiety day, eating quickly, drinking a full milkshake or can of soda, and eating just past the point of being full.

The main components of cognitive behavior therapy for emetophobia/fear of vomiting are as follows:

Education: Learn about the physiological, cognitive, and behavioral components of anxiety, the role of avoidance in maintaining symptoms and the use of symptom-induction exercises. Read introductory sections and emetophobia section in Mastery of Your Specific Phobia by Antony, Craske, & Barlow. Read a handout on the physiology of a panic attack.

Behavioral Components: Learn the rationale for situational and interoceptive exposures. Develop a hierarchy of feared situations and bodily sensations. Conduct in-session interoceptive exposure exercises to induce panic symptoms and/or nausea symptoms. Include a family member or close friend as a support person to assist with exposures outside of the therapy sessions.

Cognitive Strategies: Discuss how various “cognitive distortions” can contribute to anxiety. Use cognitive therapy techniques and behavioral experiements to examine evidence to support and refute unrealistic beliefs about vomiting.

Homework Assignments: Reading, self-monitoring, working on elements on your hierarchy through exposure sessions, behavioral experiments to challenge misinterpretations.

Ending Treatment: Review treatment gains. Discuss how to maintain gains through regular exposure to feared situations.

Common Goals of Therapy for Emetophobia/Fear of Vomiting

• Reduce fear of vomiting so that it no longer interferes with your life.
• Reduce avoidance of situations associated with emetophobia.
• Improve social and occupational functioning.

If you think you may have emetophobia, seek treatment early as the condition tends to worsens with time.