Contents

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 most people. 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 find you repulsive. As a result you try too hard to avoid a wide range of situations and activities that you believe might increase of risk vomiting.

When does a concern with vomiting 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 interference 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.

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:
a) Avoiding adults or children who could be ill (and regarded as contagious) or who may be at risk of vomiting (e.g. drunks who remind you of vomiting). The avoidance might extend to restricting activities of any children who may be in contact with other children.
b) Avoiding situations or activities such as going on holiday abroad; places where you may see drunks; visiting ill people; travelling by boat or aeroplane; drinking alcohol in normal amounts; crowded places; using public transport; pregnancy; fairground rides; using public toilets or door handles; medication; going to the dentist; anaesthesia . Women with babies might experience a great deal of distress about their child vomiting.
c) Avoiding food. Food restriction may occur in a variety of ways:
i) 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.
ii) Restricting food in certain contexts (for example, not eating food cooked by someone else or in an unfamiliar restaurant).
iii) 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.
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 excessive checking of sell by dates and freshness of food; seeking reassurance; 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" 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. 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. Even though it is probably impossible people may attempt to mentally to control the reflex act of vomiting. This makes you feel more in control but increases your preoccupation and distress.

All these avoidance, safety seeking behaviors and being extra-vigilant keep the problem going. They make you think that they 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. This becomes 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 change.

How common is emetophobia?
Specific phobias (e.g. insects, heights) are relatively common and in several large surveys occur in about 10% of the population. Of these surveys, only one study (Becker, et al, 2007) specifically asked about a phobia of vomiting and it was found to 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. However common it is, we do know that specific phobias of vomiting are generally more handicapping than other specific phobias and are more difficult to treat.
Note that we are discussing a Specific phobia of vomiting. There have been other surveys that have asked about a fear of vomiting, which is relatively common at about 10% of the population. This is different from a specific phobia of vomiting that we are discussing on these pages. A phobia is significantly distressing and interfering in one's life. A fear is just something that is distressing enough to interfere in one's life.

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 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. Do you know the rat is the only animal that cannot vomit? This is one reason why rat poison is so effective.

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 in an almost magical way. 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; a 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 each 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. Current 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 CBT in the past that has not been helpful but it may depend 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.
a) You may try to avoid thoughts and images of their self or others vomiting and feelings of nausea.
b) You are more vigilant for monitoring threats (e.g. people who could be ill or an escape route)
c) You become excessively self-focussed in order to monitor nausea
d) You worry, try to reassure yourself and mentally plan escape routes from others who might vomit
e) You may think in a magical way and neutralise the thoughts and images of vomit in a way you believe to stop yourself from vomiting
f) 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 a technique called 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 like 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 we hope to do this in the future.

What about Hypnotherapy or neuro-linguistic programming?

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

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 who has experience in phobias of vomiting for further assessment. This may lead to outpatient treatment or, if more serious, residential or inpatient treatment. See the links on this website for the Bethlem Royal Hospital for our NHS national specialist service for Specific Phobia of Vomiting.

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 phone them on 0845 4647. Alternatively try to discuss your treatment choices with family, friends, doctors or other health professionals.

Dr David Veale, FRCPsych (www.veale.co.uk)

Consultant Psychiatrist in Cognitive Behaviour Therapy, South London and Maudsley Trust and The Priory Hospital North London.