Emetophobia
On this page:
- What is emetophobia?
- What causes emetophobia and how to cope with it
- How common is emetophobia?
- Treatements available
- Current research
- Self-help
- Recommended reading
- Information for health care professionals
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 to get help in the UK. 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.
What Is Emetophobia?
Emetophobia is a condition where an individual fears vomiting or others vomiting. If you have emetophobia, you may fear vomiting alone or in public equally. You may frequently experience feeling sick but you 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 you 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 you try too hard to avoid a wide range of situations or activities that you 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 your life. For example, it may interfere with an important relationship or your social life. It may prevent you from a desired pregnancy or you may be unhealthily underweight. You 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 you have emetophobia, you are probably avoiding a range of activities or situations. These can usually be divided into:
- Avoiding adults or children who could either be ill (and are therefore regarded as contagious) or who may be at risk of vomiting (e.g. drunks and therefore remind you of vomiting). The avoidance might extend to restricting the activities of any children who may be in contact with other children at school or at a party.
- Avoiding situations or activities such as going on holiday abroad; places where you might see drunks; visiting people who might be ill; travelling by boat; travel by aeroplane; drinking alcohol in normal amounts; being in crowded places; using public transport; pregnancy; fairground rides; using public toilets or door handles; medication; going to the dentist; anaesthesia or becoming pregnant. Women with babies might experience a great deal of distress about their child vomiting.
- Avoiding food. Food restriction may occur in a variety of ways:
- Restricting the amount of food eaten that reaches your stomach, thus reducing the amount that might be vomited. Alternatively a restricted amount is equated with feeling “full”, as eating more than this could lead to vomiting.
- Restricting food in certain contexts (for example, not eating food cooked by someone else or in an unfamiliar restaurant).
- Restricting certain types of food. Certain foods (for example, shellfish, poultry, curries, dairy products and fried fast food) might have a slightly higher risk of vomiting. Alternatively, certain foods may have become associated with a past experience of vomiting which have now led to avoidance. Restricting food may lead to being underweight, which may have a number of physiological consequences. These may be a further factor in increasing anxiety and nausea.
You may also have a number of “safety seeking behaviours”. These are things you do that you believe will prevent yourself 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 yourself 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 you are going to be sick (e.g. “If water’s going down, then nothing can come up”). You may take anti-nausea medication or suck antacids ice or mints.
You might also be telling yourself certain things in your head – for example reassuring yourself that you 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 you do not vomit) but have the unintended consequence of increasing your awareness of feeling sick and the preoccupation with vomiting and making you more anxious in a vicious circle. In short, it is your 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 you know these associations are not true now, they are still powerfully linked in your mind. However, these associations can also be unlearnt and the “ghosts of the past” can be updated.
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?
You may feel demoralised or clinically depressed. Some people restrict their food believing that a range of food may cause vomiting. You 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).
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 begin to 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. You 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 you to get a good understanding of how the fear might have developed and how your solutions have now become your 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.
- You may try to avoid thoughts and images of yourself or others vomiting and feelings of nausea
- You are more vigilant for monitoring threats (e.g. people who could be ill or an escape route)
- You become excessively self-focussed in order to monitor nausea
- You worry, try to reassure yourself and mentally plan escape routes from others who might vomit
- You may think in a magical way and neutralise to stop yourself from vomiting
- You may use safety seeking behaviours including compulsive checking and reassurance seeking.
All these ways of coping make you feel that you have more control in your ability to stop yourself from vomiting or that you 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 you 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 your avoidance and safety seeking behaviours. You 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 you to do what is important in your life despite your 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 your life 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. Please beware of commercial practitioners and if you chose this route, 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 you can control yourself 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 I get help for emetophobia?
Contacting your GP is often the easiest way to get help and further treatment on the NHS. 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.
If you're worried about talking to your GP, consider writing down your concerns and questions. You can:
- take a friend or family member with you;
- see another doctor in the practice; or
- join a new GP practice.
Some areas now allow you direct access to a new psychological treatment centre (without going through your GP). These are part of the new NHS Improving Access to Psychological Therapies centres.
NHS Direct can offer you advice on moving to a new GP practice. You can visit the website at NHS Direct or phone them on 0845 4647. Alternatively try to discuss your treatment choices with family, friends, doctors or other health professionals.
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 your GP’s registered address and the service agreements our hospital has agreed with your 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 4051In 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 you 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 you have accepted an appointment you 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 you 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 you to come back. You will be asked detailed questions about your problem with emetophobia and any other problems you may have. It is important that we get a very clear understanding of your problems in order to establish what kind of help you may need. We will not make a decision about what is the best way to proceed on the day. We will consider your case and discuss it with the team, and aim to let you know within a couple of weeks. If we feel we can help you 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 you are significantly underweight or need nursing care then we will discuss recommending other options on the NHS. If, at assessment, we do not feel we are able to help you then we tell you the reasons for this and suggest more helpful ways for you to proceed towards finding help for your 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.
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.
- We are conducting a study shortly that aims to create a new questionnaire that will be able to measure the severity of emetophobic symptoms and help therapists track the changes in symptoms over time. We are also trying to find out how often people with emetophobia vomit in a given year compared to the general population. This will involve filling in some questionnaires online and keeping a record of each time you vomit over the next 2 years.
- We are also about to start a study that involves a detailed interview about the development of your emetophobia.
If you would be interested in participating in this research or would just like some more information please contact Nell by email on Nell.Ellison@kcl.ac.uk or by phone on 0203 228 3212. By replying you do not commit yourself to anything, she will simply give you some more information and give you the opportunity to ask questions. Your assistance will be greatly appreciated.
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:
- Gut Reaction - www.gut-reaction.freeserve.co.uk
- International Emetophobia Society - www.emetophobia.org
- Emetophobics Proboard - http://emetophobics.proboards83.com/index.cgi
- Fear of Vomiting http://health.groups.yahoo.com/group/fov/
Information for health care professionals
Some of the questionnaires used by our clinicians for assessment and treatment of specific phobia of vomit can be found on our questionnaires for clinical use page.
Recommended Reading About Emetophobia
One book has been published by a person with emetophobia
- Living with Emetophobia: Coping with and Extreme Fear of Vomiting by Nicolette Heaton-Harris is published by Jessica Kingsley Publishers (ISBN 9781843105367)
References
These are, as far as we know, all references on Emetophobia or a Specific Phobia of Vomiting in the scientific literature from which this information was compiled.
- Becker, E. S., M. Rinck, et al. (2007). "Epidemiology of specific phobia subtypes: findings from the Dresden Mental Health Study."European Psychiatry 22: 69-74
- Boschen, M. J. (2007). "Reconceptualizing emetophobia: a cognitive-behavioral formulation and research agenda." Journal of Anxiety Disorders 21(3): 407-19
- Boyd, J. H., D. S. Rae, et al. (1990). "Phobia: prevalence and risk factors." Social Psychiatry and Psychiatric Epidemiology 25(6): 314-323
- Davidson, A., C. Boyle, et al. (2008). "Scared to lose control? General and health locus of control in females with a phobia of vomiting." Journal of Clinical Psychology 64(1): 30-39
- Garcia, J. R., K. W. Rusiniak, et al. (1977). Conditioning food-illness aversions in wild et al. (1993). Cognitive behavioural therapy for panic disorder with a primary fear of vomiting: conceptual and treatment issues. Proceedings for Association for Advancement of Behaviour Therapy. Atlanta, GA, USA
- Kessler, R. C., W. T. Chiu, et al. (2005). "Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication." Archives of General Psychiatry 62(6): 617-627
- Lesage, A. and Y. Lamontagne (1985). "Paradoxical intention and exposure in vivo in the treatment of psychogenic nausea: Report of two cases." Behavioural Psychotherapy 13(1): 69-75
- Lipsitz, J. D., A. J. Fyer, et al. (2001). "Emetophobia: preliminary results of an internet survey." Depression & Anxiety 14(2): 149-52
- Lydiard, B. R., M. T. Laraia, et al. (1986). "Can Panic Disorder Present as Irritable Bowel Syndrome?" Journal of Clinical Psychiatry 47(9): 470-473
- Manassis, K. and E. Kalman (1990). "Anorexia Resulting from Fear of Vomiting in Four Adolescent Girls." Canadian Journal of Psychiatry 35: 548-550
- McFadyen, M. and J. Wyness (1983). "You don't have to be sick to be a behaviour therapist but it can help! Treatment of a 'vomit' phobia." Behavioural Psychotherapy 11(2173-176): 173-176
- McKenzie, S. (1994). "Hypnotherapy for Vomiting Phobia in a 40-Year-Old Woman." Contemporary Hypnosis 11(1): 37-40
- McNally, R. J. (1997). Vomiting phobia. Phobias: a handbook of theory, research and treatment. G. C. Davey. Chichester, Wiley: 186-187
- Moran, D. J. and R. M. O’Brien (2005). "Competence imagery: a case study treating emetophobia." Psychological Reports 96: 635-636
- O'Connor, J. J. (1983). "Why can't I get hives: brief strategic therapy with an obsessional child." Family Process 22(2): 201-9
- Ohman, A. and S. Mineka (2001). "Fears, phobias, and preparedness: Toward an evolved module of fear and fear learning." Psychological Review 108(3): 483-522
- Philips, H. C. (1985). "Return of Fear in the Treatment of a Fear of Vomiting." Behaviour Research Therapy 23(2): 45-52
- Ritow, J. K. (1979). "Brief Treatment of a Vomiting Phobia." The American Journal of Clinical Hypnosis 21(4): 293-296
- Stinson, F. S., D. A. Dawson, et al. (2007). "The epidemiology of DSM-IV specific phobia in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions." Psychological Medicine 37: 1047-1059
- van Overveld, M., P. J. de Jong, et al. (2008). "An internet-based study on the relation between disgust sensitivity and emetophobia." Journal of Anxiety Disorders 22(3): 524-531
- Veale, D. and C. Lambrou (2006). "The psychopathology of vomit phobia." Behavioural and Cognitive Psychotherapy 34(2): 139-150
- Veale, D (in press) Treating a Specific Phobia of Vomiting. The Cognitive Behaviour Therapist
- Wijesinghe, B. (1974). "A Vomiting Phobia Overcome by one Session of Flooding with Hypnosis." Journal of Behavioural Therapy and Experimental Psychiatry 5: 169-170
- Wolitzky-Taylor, K. B., J. D. Horowitz, et al. (2008). "Psychological approaches in the treatment of specific phobias: A meta-analysis." Clinical Psychology Review 28(6): 1021-1037