by Allen H. Weg, EdD
Allen H. Weg, EdD, is the Executive Director of Stress and Anxiety Services of New Jersey, Inc. He is on the Scientific and Clinical Advisory Board of the International OCD Foundation (IOCDF) and President of the IOCDF affiliate, OCD New Jersey.
This article was initially published in the Fall 2017 edition of the OCD Newsletter.
I had never heard of the term “emetophobia” until about 15 years ago when a 12 year-old girl was referred to me with what sounded like a very typical OCD diagnosis — obsessive thoughts focusing on the fear of germs. She was reportedly anxious of anyone, anything, or any place that could potentially expose her to germs that could make her sick. She avoided all public places, refusing to use public restrooms, go to amusement parks, or attend any event where there might be a crowd of people. She would not eat at all when visiting restaurants or friends’ houses, and ate only foods that her mother would prepare at home. In addition to this, she washed her hands compulsively.
The Importance of a Proper Assessment
Since most of the clients in my practice had some form of OCD, I was quite familiar with this particular group of symptoms. My initial expectation was that treatment would proceed with a straightforward application of exposure and response prevention (ERP) therapy aimed at increasing levels of contamination triggers. However, when I interviewed the girl and her parents, they revealed other symptoms that did not fit with the typical diagnosis of OCD “germaphobia.” For example:
- The girl asked multiple questions, seeking reassurance that food items were properly refrigerated or cooked.
- She usually inspected the expiration and sell-by dates on food packages and labels.
- She was reportedly afraid of things that might have a “bad smell” and refused to let her parents stop at a gas station when she was riding in the car with them, complaining that the “gas smells” made her anxious.
- Movies and TV shows were difficult for her to watch because she reported fearing that scenes would come up that might be bloody or gory.
When treating a client with anxiety, a therapist properly utilizing cognitive behavioral therapy (CBT) for OCD knows that you cannot treat someone effectively until you can precisely answer the question, “What exactly is it that the client is afraid of?”
Upon further inquiry, it seemed that the girl was not afraid of germs that might make her sick with an illness such as a fever or cold. She was specifically afraid of germs, spoiled food, bloody scenes on TV, and gas fumes because they might make her nauseated, resulting in her vomiting. In other words, she was suffering from emetophobia, an intense fear of vomiting.
Symptoms of Emetophobia
As with OCD, emetophobia symptoms can be debilitating and affect the client’s quality of life in various ways.
- Typically, in emetophobia, only a few “safe” foods are eaten, and the patterns of avoidance may not make sense to the casual observer. For instance, an emetophobic may avoid bread products due to a fear of mold, yet may be perfectly fine eating fried, fatty foods, which most people would think of as more likely to lead to nausea or vomiting.
- Consumption of other things may also be avoided, such as alcohol or over the counter and prescription medications, the latter of which often have written right on the label that nausea may be a possible side effect.
- Emetophotics may avoid eating too quickly or eating later in the day, and food intake of any kind, including water, may be restricted to the home.
- Adults with emetophobia may avoid social venues, such as bars or parties, where they expect significant amounts of alcohol will be consumed.
- An individual with emetophobia’s work may suffer because they avoid travel, work related social activities, or the employee cafeteria.
- Women who yearn to be mothers may forgo pregnancy for fear of morning sickness.
- Children may avoid their school’s cafeteria, gym, or the bathroom, or may experience complete school refusal due to their fear of vomiting or exposure to someone who may vomit.
- The “phobic net” may be cast wide for both children and adults, and may include fear of flying, public transportation, hospitals, or any place where there may be crowds.
- There may be hyper-vigilance and hyper-reactivity in response to a person burping, coughing, looking pale, or even people placing their hand on their stomach.
Struggles with all of these issues often result in depression, shame, secrecy, and lies.
Diagnosis (and differential diagnosis) of Emetophobia
Emetophobia is often diagnosed as a Specific Phobia. However, because the most prominent symptoms often meet the criteria for obsessive compulsive disorder, OCD may be the more appropriate diagnosis. This seems especially true in the following instances:
- The patient experiences irrational thoughts such as, “I wore a green shirt when I saw that girl vomit, so now I avoid wearing anything green.”
- The patient experiences intrusive, ruminative thoughts revolving around the fear of being exposed to germs and then responds with excessive washing, checking, avoidance, and the use of safety items such as always carrying around a bottle of water.
In both cases, there is obsessional thinking, hyper-awareness and reactivity, avoidance, compulsive rituals, and safety behaviors.
Additionally, while the specific symptoms of emetophobia vary widely, they most often include severe restriction of food intake, resulting in what may look like a type of avoidant/restrictive food intake disorder (ARFID). Like ARFID, emetophobia involves restricted food intake that is not based on distortion of body image, nor an expressed desire to lose weight. Yet, significant weight loss can and does occur in individuals with emetophobia, as is always the case with ARFID. Additionally, both disorders often involve avoidance of foods based on their color or texture. The boundaries between these diagnoses are somewhat unclear, but the majority of ARFID cases do not specifically include a fear of vomiting, therefore those cases would clearly not be persons with emetophobia.
Treatment of Emetophobia
The task of the clinician is to ultimately trace the client’s symptoms to the fear of vomiting. As with other forms of OCD, once identified as a case of emetopobia, exposure and response prevention (ERP) as well as cognitive therapy can be applied as the core treatment.
In emetophobia treatment, ERP is best applied to three different areas of the emetophobic symptoms:
- The first area is the physiological symptoms associated with nausea and vomiting itself, which trigger anxiety. To address the physiological symptoms, we would have the client engage in interoceptive cue exposure (sometimes called symptom cue exposure). In this treatment, the client purposely creates physical symptoms associated with nausea and vomiting by engaging in certain self-controlled exercises.These exercises may vary, but can include things like spinning in place or hyperventilation, both of which can cause nausea, dizziness, and light-headedness (physician approval may be required if the person suffers from certain medical conditions such as COPD). Exposures are done repeatedly, following a specific schedule, while anxiety levels are monitored (a numbered scale of Subjective Units of Distress, or SUDs, is usually used).
- A second area are the environmental triggers of emetophobic anxiety. Targeting the environment triggers may include going places that have been avoided such as bars, lunchrooms, or public bathrooms. ERP is conducted exactly as one would do for OCD avoidance behaviors, where a hierarchy is established and followed, and the client moves up that hierarchy as anxiety is better managed. Another environmental exposure focus involves exposure to the avoided foods themselves, and is treated similarly through ERP therapy.Once well tolerated, these above exposure experiences may be combined during treatment. For example, a person could hyperventilate creating feelings of nausea and then immediately eat a certain food that had previously been avoided, all while in an environment that had previously been avoided, such as in a restaurant.
- A final area of treatment involves exposure to the act of vomiting itself. I do not require or recommend having the emetophobic vomit, because I do not think it necessary for recovery. Instead, therapy involves having the emetophobic engage in simulated vomiting. In this case, a concoction of some sort is created to represent the vomit (e.g., canned beans mixed with corn and peas). The person stands or kneels in front of the toilet with the seat up, takes a mouth full of the bean mixture in his mouth, and spits it into the toilet repeatedly, flushing afterwards each time. The amount of mixture used each time can also be varied, often starting with tiny amounts at the initial trials and adding more as exposure progresses.In addition to the method above, exposure to vomiting itself can be done on the Internet. The best resource I have come across for this is the web site, www.EmetophobiaResource.org. It is a wonderful at home, self-paced program for emetophobia exposure that arranges letters, words, sentences, stories, drawings, photos, videos, and sounds of vomiting into a self-administered, hierarchy exposure experience.
Cognitive therapy would be incorporated into all parts of the ERP interventions mentioned above. Cognitive work emphasizes challenging the patient’s negative patterns of thought, as well as challenging one’s misperceptions of what is thought of as “too scary” or “too difficult” given what amount of progress they have already made.
Once a professional can understand and properly diagnose emetephobia, they can began treating through ERP. Interventions are first demonstrated and practiced in the office when possible, and may then be assigned as homework practice.
Interoceptive exposure, environmental exposure, and simulated vomiting exposure (including online exposure programs) can be combined with cognitive therapy to move the emetophobic forward in confronting fears, allowing for greater behavioral freedom, and/or lowered anxiety.
My experience has indicated that, when a motivated and disciplined client is engaged, this combination of interventions can result in substantial improvement and often a complete elimination of symptoms.
- Barlow D, Craske, M: Mastery of Your Anxiety and Panic: Edition 4. New York, Oxford University Press, 2006.