Emetophobia: when a fear of vomiting holds you back in life
By Giulia Villa
Many things that can be unpleasant or scary can be an unfortunate part of life: Spiders, heights, needles, flying. In this article, we’ll be talking about another addition to this category. That’s right - vomit. Among specific phobias, emetophobia, or an extreme fear of vomiting, is one not often spoken about. Keep reading to learn more about:
Why emetophobia is so debilitating
About emetophobia: What is emetophobia, and what makes it unique
Spotting the signs of emetophobia
Emetophobia, eating disorders, and OCD
Treatment options for emetophobia
And if you’re unsure about the difference between a phobia and the experience of fear or anxiety – take a look at this page where we clarify the distinction between these concepts in more detail.
How debilitating can a fear of vomiting be?
To those who don’t experience it, a fear of vomiting may not seem that problematic – after all it could be a low frequency event as some people do not vomit for years. However, emetophobia is so much more than that. Unlike, say, a fear of heights and flying which can usually be avoided, a fear of vomiting means chronic hypervigilance and manoeuvring for a wide range of everyday situations in which vomiting may be possible. Some examples include:
Your study group wants to go to a local cafe for lunch whilst you’re all working hard on a group assignment. Unfortunately you can’t take your own food in! You don’t know your study group that well, so you feel the pressure to go along with the groupthink. Whilst you’re there, there are all sorts of smells that make you want to gag… cheeseburgers, fish sauce, parmesan… it’s a minefield.
Your out-of-town relatives are visiting for the first time ever and really want to take a boat to an island to see quokkas which they won’t find anywhere else in the world. The mere thought of being stuck on a boat and experiencing motion sickness strikes fear into your heart.
There’s a morning tea at work to celebrate finishing a big project that you’ve played an important part in. However, you avoid going as you don’t want to eat or drink, and don’t want to spend that time explaining yourself.
You’ve been invited to a close friend’s wedding reception at a winery. Unfortunately there’s food you would not usually eat that’s been prepared by someone else, and the other guests will be people drinking alcohol. To top it all off…the winery is a 40-minute drive away along winding roads and your friend has organised a bus to and from the reception so that everyone can “feel more comfortable”.
From the above examples, it’s clear that a fear of vomiting can really affect daily life. Given its wide-ranging impact, let’s take a closer look at what emetophobia is.
What is emetophobia?
Emetophobia is an anxiety disorder which falls under the classification of a specific phobia. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) [1] defines a specific phobia as:
An intense fear or anxiety about a specific object or situation that lasts at least 6 months
The phobic object/situation always provokes immediate fear or anxiety
The phobic object/situation is actively avoided or endured with intense fear or anxiety
The fear or anxiety is disproportionate to the actual threat posed by the phobic object or anxiety
The fear, anxiety or avoidance causes significant impairment to daily functioning e.g. not being able to eat food cooked by others, not seeing friends and family, not going to work etc.
The fear, anxiety or avoidance isn’t better explained by another medical disorder
Emetophobia is thought to affect between 0.1% and 0.2% of the population [2], though this is thought to be a conservative estimate [2], and usually starts in childhood or early adolescence. This condition is more common in women than in men.
what makes emetophobia unique
At its core, emetophobia shares many similarities with other specific phobias - intense fear, anxious thoughts, and avoidance. However, there are certain characteristics that are unique to the fear of vomiting which are important to consider:
Control in emetophobia
A distinct belief held by many people with emetophobia is that, if necessary, they can exercise enough physical control over themselves and their environment to prevent vomiting. Most people with emetophobia have not thrown up in a considerable length of time, and they credit their strategies (or safety behaviours, which we will look at in more detail) for this. In the context of treatment, this belief can make it very difficult for individuals to let go of such safety behaviours and coping mechanisms as they believe these are vital.
Gastrointestinal anxiety symptoms in emetophobia
A common feature of anxiety is stomach and intestinal discomfort. This is because of the strong connection between the brain and the body’s gastrointestinal system. When stress or anxiety becomes significant enough to trigger a fight-or-flight response, our body suppresses digestive functions in order to redirect resources to other areas and can lead to a reduced appetite, nausea, stomach pain/cramps, acid reflux, butterflies, and irregular bowel movements. With emetophobia this gets tricky, as intestinal discomfort can be anxiety-provoking in itself, catapulting individuals into worrying about whether they’re about to be sick.
This creates a vicious cycle, where the intense fear and anxiety around vomiting leads to physical sensations, which intensify the anxiety felt by the emetophobic individual. Over time, someone with emetophobia may become hypervigilant of their bodily sensations, constantly directing their attention towards sensations that could suggest the possibility of vomiting. For a person with emetophobia, a tummy gurgle or a brief wave of nausea has the power to trigger a spiral of anxious thoughts. Avoidance of vomiting then reinforces this cycle.
Spotting the signs of emetophobia
How do you know if you have emetophobia rather than just a dislike of vomiting? In addition to the chronic intense and disproportionate fear and anxiety in relation to vomiting, consider the role of avoidance and how it interferes with your daily life. Below are some common signs of avoidance that we commonly see in emetophobia - monitoring your environment on an ongoing basis to avoid these threats can be extremely debilitating indeed.
What’s the difference between Emetophobia, Eating disorders, and Obsessive Compulsive Disorder?
The lack of current research and training around emetophobia mean that this condition is unfortunately often misdiagnosed. Most commonly, emetophobia may at times be misdiagnosed as Anorexia Nervosa (AN) or Obsessive Compulsive Disorder (OCD) due to similarities between the conditions. Below we outline common and distinct features of these conditions in comparison to emetophobia.
Emetophobia and Anorexia Nervosa (AN)
People with emetophobia may restrict the types and quantity of food that they eat, in order to reduce or eliminate the risk of being sick, which might result in significant weight loss. Restriction of food is also a key feature of AN, but in the case of AN the restriction serves the purpose of weight control rather than avoidance of vomiting. Another key difference in these diagnoses is that AN is characterised by an intense fear of gaining weight and a sense of self-worth that is heavily influenced by one’s weight or shape (DSM-5). These features are not present in emetophobia, where the fear itself is of the act of vomiting.
emetophobia and Obsessive Compulsive Disorder (OCD)
Individuals with emetophobia may also take measures like excessive hand-washing and wearing a face mask to reduce the risk of contracting an illness that may lead to vomiting. Obsessive, persistent, and distressing thoughts that revolve around fear of exposure to germs are a symptom that might also both present in emetophobia and OCD.
An important distinction between a diagnosis of OCD and emetophobia is the presence or absence of magical thinking and ritualistic safety behaviours. While both conditions can involve seemingly irrational thoughts and excessive behaviours, the context and motivation behind these actions can help differentiate between the two conditions.
Magical thinking is a feature of OCD which refers to the belief that a person’s thoughts or actions have a very real potential to influence events, even in the absence of a logical cause-and-effect connection between the two. For example, someone with contamination OCD might think "If I don't wash my hands exactly seven times after touching a doorknob, I'll get sick and start vomiting." In emetophobia whilst the act of hand washing is seen to reduce the likelihood of contamination, there is not stipulation around the number of times this is to be performed.
Ritualistic behaviours are also a feature of contamination OCD that can distinguish it from emetophobia. Rituals and other neutralizing behaviours are a hallmark of OCD. These compulsions, (e.g. repetitive hand washing, excessive cleaning, checking, counting, arranging objects in a specific way) are carried out in an attempt to prevent feared outcomes (i.e., vomiting) or reduce the anxiety caused by obsessive, irrational thoughts. Thus, someone may wash their hands exactly seven times, and in a prescribed order (and, if interrupted when performing this ritual, will feel compelled to restart the ritual again).
Individuals with emetophobia may also engage in similar excessive behaviours like frequent hand-washing or avoiding certain foods, however these actions do not have a ritualistic flavour to them but instead these behaviours (frequency, number) have a straightforward link to preventing vomiting. For example, someone with emetophobia who fears contracting a stomach virus may thoroughly wash their hands once. However, they are unlikely to believe in washing their hands a specific number of times or in a particular way in order to guarantee that they won't become ill.
Treatment options – what works for emetophobia
The recommended treatment for all specific phobias is Exposure Therapy as part of Cognitive Behaviour Therapy (CBT). Essentially, this involves facing vomit-related fears, and thus the thought of exposure therapy can be incredibly intimidating as it involves confronting the very subject of fears.
Facing something that we are scared of is daunting, which is why it’s important to work with a trained professional who can guide you at a pace that stretches you but does not create excessive fear. The goal of exposure therapy is to shift your fear of vomiting, help your body to adjust to the increase in anxiety in that situation, and then to help you recognise your ability to cope.
Treatment for emetophobia needs to be highly tailored to the individual, because different people experience the phobia in different ways and intensities. Working with a psychologist helps with considering where the individual is at, what typical triggers there are, and what avoidance strategies are in place. Consider:
Ty may have a fear of vomiting and overestimates the likelihood of himself vomiting. He works as a librarian in administration and is not often exposed to people vomiting, nor is he concerned by others vomiting. Ty’s main concern when it comes to vomiting is in his personal life – his friends are all hitting the age of weddings and he anticipates having to eat many foods that he considers ‘unsafe’.
Priya is a doctor who will be rostered to work in the gastroenterology department in a few months’ time. She cannot stand seeing others vomit and is very worried about catching illnesses from people who are unwell. Needless to say, her emetophobia makes work extremely challenging. Priya also wants to start a family in the near future, but experiences extreme fear due to the prospect of feeling nauseous due to morning sickness.
Thus, whilst both Ty and Priya have emetophobia, treatment will look different for them due to the differences in triggers, situations where they have to face vomiting, and the impact on their lives.
What does treatment of vomit phobia look like?
After a thorough and individualised assessment, a therapist will guide you through systematically increasing your tolerance to these three key areas:
The physical sensations associated with vomiting (e.g. nausea, stomach pain).
Vomit-related triggers like words, pictures, sounds, and videos
Environmental triggers, such as food, smells, and public places
Treatment for emetophobia also involves a cognitive component which aims to challenge and restructure unhelpful thoughts and beliefs that are contributing to the fear. Working one-on-one with an experienced clinician means that you will be receiving a tailored approach that will provide you with adaptive skills to take into your life outside of therapy.
Here at The Skill Collective we work with emetophobia – and the following psychologists in our team have a passion for exposure therapy, so why not book in and get started on shifting this debilitating fear?
REFERENCES
[1] American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington: American Psychiatric Publishing.
[2] Becker E, 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,22,69–74. doi: 10.1016/j.eurpsy.2006.09.006.
[3] Sykes, M., Boschen, M. J., and Conlon, E. G. (2016) Comorbidity in Emetophobia (Specific Phobia of Vomiting). Clinical Psychology & Psychotherapy., 23: 363–367. doi: 10.1002/cpp.1964.
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