Emetophobia

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Emetophobia is the common name for a Specific Phobia of Vomiting. It is a condition that is often misunderstood and may be difficult to treat. However it is treatable and this website aims to help you understand emetophobia – its causes, effects and how sufferers in the UK can get help. Knowledge in this area is limited because of the lack of research or any controlled trials. This information is written for people with emetophobia and their relatives, friends or carers and will also be useful for health professionals treating this condition.

What Is Emetophobia?

Emetophobia is a condition where an individual fears vomiting or others vomiting. If a person has emetophobia, they may fear vomiting alone or in public equally. They may frequently experience feeling sick but they are probably no more at risk of being sick than someone else without emetophobia who does not get drunk or take illegal drugs. It may have become a preoccupation and the only thing they think about. Vomiting is associated with an overwhelming fear and panic. Some people fear losing control, becoming very ill or that others will find them repulsive. As a result they try too hard to avoid a wide range of situations or activities that they believe might increase risk of vomiting.

When does a concern with vomit become a phobia?

Vomiting upsets many people, but to be diagnosed with a Specific Phobia of Vomiting it must be very distressing and have an important effect on the person's life. For example, it may interfere with an important relationship or their social life. It may prevent them from a desired pregnancy or they may be unhealthily underweight. They may not be able to go on holiday or travel on public transport.

What causes emetophobia and how to cope with it

How do people with emetophobia cope?

If a person has emetophobia, they are probably avoiding a range of activities or situations. These can usually be divided into:

Someone suffering from emetophobia may also have a number of “safety seeking behaviours”. These are things they do that they believe will prevent them or others from being sick. These include compulsive checking of sell by dates and freshness of food; reassurance seeking; excessive cooking of food; excessive washing of hands or cleaning of the kitchen area with anti-bacterial sprays and gels; superstitious behaviours such as “not stepping on a 13th stair” or repeating a word or action a certain number to prevent them from vomiting. People with emetophobia frequently drink bottled water or a sugar fizzy drink, which they carry around with them. These behaviours may also be a way of checking whether they are going to be sick (e.g. “If water’s going down, then nothing can come up”). They may take anti-nausea medication or suck antacids ice or mints.

They might also be telling themselves certain things in their head – for example reassuring themselves that they or someone else will not be sick. People may attempt to mentally control the reflex act of vomiting (which is probably impossible).

All these avoidance, safety seeking behaviors and being extra-vigilant keep the problem going. They appear to work (in the sense that the person does not vomit) but have the unintended consequence of increasing their awareness of feeling sick and the preoccupation with vomiting and making them more anxious in a vicious circle. In short, it is their solutions that have become the problem and are now maintaining the fear.

What causes emetophobia in the first place?

We don’t know but some people may be genetically predisposed to developing a specific phobia. It is intriguing that emetophobia is much more likely to occur in women. Men with emetophobia are uncommon.

Developing a specific phobia of vomiting is highly understandable given the way that humans (and animals) can become easily conditioned after food–poisoning or an infection and are more likely to avoid situations that remind them of vomiting. Vomiting as a baby or as a child could be very panic inducing (for example the association with the feeling of suffocating, choking or death). Even if as an adult people know these associations are not true now, they are still powerfully linked in the sufferer's mind. However, these associations can also be unlearnt and the “ghosts of the past” can be updated.

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How common is emetophobia?

Specific phobias (e.g. insects, heights) are relatively common and occur in about 10% of the population. In very large surveys, only one study (Becker, et al, 2007) specifically asked about a phobia of vomiting and it was found to be relatively uncommon at 0.1% of the population. In another very large study of Specific Phobias, they did not specifically ask about the fear of vomiting and the number who volunteered was too small to analyse (Stinson et al, 2007). However it's hard to say exactly how many people have a Specific Phobia of Vomiting as some may be misdiagnosed as having Obsessive Compulsive Disorder or Health Anxiety. Many people with emetophobia are also too ashamed to talk about their problem. It is however agreed that specific phobias of vomiting are generally more handicapping than other specific phobias and are more difficult to treat.

Is emetophobia linked with other illnesses?

Someone with emetophobia may feel demoralised or clinically depressed. Some people restrict their food believing that a range of food may cause vomiting. They may then become very underweight and some people with emetophobia may be misdiagnosed with anorexia nervosa.

How is the condition likely to progress?

No long-term follow up studies have been done. Many people with emetophobia have a chronic condition. If left untreated, then the condition is likely to persist.

Why do humans and animals have to vomit?!

Vomiting is an adaptive process that increases your chances of survival if you are ill. If you are infected, vomiting is beneficial and prevents disease by getting rid of toxins. People with emetophobia may believe that if vomiting did occur then it will last for many days. In fact, after an infection or food poisoning, it usually lasts at the most a day or two.

Others believe that they can influence or control their vomiting. However, the act of vomiting is a primitive reflex act that cannot be inhibited. People with emetophobia tend to focus on the risk of infection or food poisoning but the reflex can be triggered by a wide variety of triggers around the body (e.g. mechanically in gynaecological problems; an extremely stretched gall-bladder or stomach; by certain drugs; metabolic problems that act on the brain stem; extreme fear; severe pain; certain smells can all induce vomiting in the right context).

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Treatments available?

There are treatments available that are described here in turn. There has been very little research to know the best treatment for emetophobia. This is why our centre is conducting research so we can slowly understand more about the cause and treatment. Treatments described include cognitive behaviour therapy, hypnotherapy and medication.

What is Cognitive Behaviour Therapy?

There is a lot of evidence for the benefit of cognitive behaviour therapy (CBT) in other phobias and obsessive compulsive disorder (see various NICE guidelines) . CBT can be adapted for treating a Specific Phobia of Vomiting. Sufferers may have had CBT in the past that has not been helpful but it partly depends on who is delivering it and the approach used. There are no miracle cures – it is hard work on the part of the individual with emetophobia.

Cognitive behaviour therapy (CBT) consists of a structured programme of self-help, helping people to get a good understanding of how the fear might have developed and how their solutions have now become the problem and keeps the fear going. It is based on an understanding that people with emetophobia have had one or more bad experiences of vomiting from childhood. Sometimes these experiences can be remembered, sometimes not. These memories have become associated with fear. Past experiences of vomiting (and their triggers) become fused with the present so that they are re-experienced as if they are about to be repeated. Once the link with the past experience is learnt, the anticipation of vomiting leads to anxiety. Anxiety causes nausea and other stomach symptoms. This becomes linked to the idea of vomiting and losing control. This is associated with extreme fear and past experiences of vomiting in a vicious circle.

There are then various ways that people with emetophobia cope with the idea of vomiting. These are not bizarre – it is a very natural response to fear.

  1. They may try to avoid thoughts and images of themselves or others vomiting and feelings of nausea
  2. They are more vigilant for monitoring threats (e.g. people who could be ill or an escape route)
  3. They become excessively self-focussed in order to monitor nausea
  4. They worry, try to reassure themselves and mentally plan escape routes from others who might vomit
  5. They may think in a magical way and neutralise to stop themselves from vomiting
  6. They may use safety seeking behaviours including compulsive checking and reassurance seeking.

All these ways of coping make people feel that they have more control in their ability to stop themselves from vomiting or that they are doing something to reduce uncertainty. However they will have the unintended consequence of increasing the frequency of thoughts about vomiting and symptoms of nausea and make the sufferer more anxious in a vicious circle. The solution therefore involves some combination of (a) updating early memories of vomiting by using imagery rescripting and (b) gradually dropping thier avoidance and safety seeking behaviours. Sufferers will not be asked to induce vomiting – this is not necessary. There are no risks or side effects of CBT other than the experience of anxiety and old memories.

Having emetophobia can make life very restricted and part of therapy will focus on helping the person with emetophobia to do what is important in their life despite their fears. Over time the degree of distress and preoccupation with vomiting should decrease. We are not saying it is easy but it is definitely possible to make the life of the person with emetophobia more manageable. There are no published rates of success using CBT, but this is something our own unit will do in the future.

What about Hypnotherapy?

There is no evidence in the literature apart from one case study for the benefit of hypnotherapy in emetophobia. Service users should beware of commercial practitioners and if they chose this route, they should check that they belong to a recognised body such as the United Kingdom Council for Psychotherapy.

What about medication?

Anti-nausea medication is often prescribed at the request of people with emetophobia. However it doesn’t solve the problem and this is usually unhelpful in the long term as it reinforces the idea that the person with emetophobia can control him/herself from vomiting.

There is no evidence from any controlled trials that medication is of any benefit in emetophobia. There is a rationale for a type of medication called a selective serotonergic reuptake inhibitor (SSRI) in those with severe symptoms that overlap with Obsessive Compulsive Disorder (OCD) and who are unresponsive to Cognitive behaviour therapy (CBT). Nausea is a potential side-effect of a SSRI which may mean that it is an unacceptable approach.

How can people who suffer get help for emetophobia?

Initially they should contact their GP in order to get help and further treatment on the NHS. They should ask to be referred for cognitive behaviour therapy or to a specialist in phobias for further assessment. This may lead to outpatient treatment or, if more serious, residential or inpatient treatment. Below are details for a national specialist service for Specific Phobia of Vomiting at the Bethlem Royal Hospital.

Some areas now allow service users direct access to a new psychological treatment centre (without going through their GP). These are part of the new NHS Improving Access to Psychological Therapies centres.

National Specific Phobia of Vomiting Service, Bethlem Royal Hospital

Our unit provides a specialist cognitive behaviour therapy service on the NHS. There are various referral routes, which depend on the service user's GP’s registered address and the service agreements our hospital has agreed with the service user's local Primary Care Trust (PCT). From a few areas (especially locally in South London) we can receive a referral direct from a GP. However, for the majority of areas the referral must come to us via the local Community Mental Health Team to enable us to obtain authorisation to offer an assessment, and/or treatment.

A written referral should be sent to:
Dr David Veale
Anxiety Disorders Residential Unit
The Bethlem Royal Hospital
Monks Orchard Road
Beckenham, Kent BR3 3BX
Tel: 020 3228 4146
Fax: 020 3228 4051

In certain cases, once we have received the referral we would have to approach the local PCT on an individual basis to request authorisation to offer our service. This is quite a routine thing to happen, similar to any specialist services that are required on the NHS i.e. the service user starts at their local hospital, but if more specialist expertise is necessary they may be referred on to a more expert specialist in the disorder they have. We endeavour to offer a choice of appointment within 13 weeks of the date of the authorised referral.

Once the service user has accepted an appointment they will be sent out some rather lengthy, but very important questionnaires covering different aspects of Specific Phobia of Vomiting, anxiety and depression. It is important that these are completed prior to the assessment and brought with them on the day. The assessment appointment usually takes at least 2 hours; sometimes it can take longer in which case we may need to ask them to come back. Service users will be asked detailed questions about their problem with emetophobia and any other problems they may have. It is important that we get a very clear understanding of the person's problems in order to establish what kind of help they may need. We will not make a decision about what is the best way to proceed on the day. We will consider their case and discuss it with the team, and aim to let them know within a couple of weeks. If we feel we can help them there is normally a wait of 3 months before we are able to start out-patient therapy. If we think a more intensive programme is required then we may offer admission to our residential unit.

If the person is significantly underweight or needs nursing care then we will discuss recommending other options on the NHS. If, at assessment, we do not feel we are able to help the person then we tell them the reasons for this and suggest more helpful ways for them to proceed towards finding help for their problems.

Finding help privately

The British Association of Behavioural and Cognitive Psychotherapists can also provide a list of accredited cognitive behaviour therapists, both private and NHS. A searchable list of private practitioners can be found on their website CBT register.

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Current Research

There is still a lot to learn about emetophobia and we are about to carry out various research projects that aim to help us find out more so we can improve on treatment.

If your service user would be interested in participating in this research or would just like some more information please contact Nell by email on Nell.Ellison@iop.kcl.ac.uk or by phone on 0203 228 3212. By replying the service users does not commit her/himself to anything, Nell will simply give them some more information and give them the opportunity to ask questions. Your assistance will be greatly appreciated.

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Self-help

Self-help may be useful as the first stage of treatment or alongside other treatments. They can help people and families understand that they are not alone, and offer valuable support and practical advice.

There are non-commercial websites and bulletin boards for people with emetophobia. These include: