Coping With Emetophobia – The S.T.A.R. Plan

Often before people with a fear of vomiting can get help they are left alone, terrified and feeling hopeless. They might not even know that being afraid of vomiting has a name: emetophobia. Some academics refer to it as “Specific Phobia of Vomiting” or SPOV. The treatment for emetophobia involves making a list of all the things that you avoid because you’re afraid, and all the safety measures you employ so you don’t get sick. This website has a “Resources” section that thousands of therapists already use for gradual exposure to some of those things. You start with the easiest thing on the list and work your way to the most difficult. You’ll normally need the help of a qualified therapist with experience treating emetophobia.

The goal in treating emetophobia is to have you come to the realization that vomiting isn’t the problem – anxiety is the problem. Once you get there, you’ll be able to tolerate your anxiety and do nothing to stop it. And once that happens, you will stop getting anxious in the first place. For some of you reading this, that may seem like a long way off. Others of you may think (as I once did) “I’ll never be able to tolerate that much anxiety! It’s terrifying and horrible!” It’s true that tolerating anxiety that goes immediately from 0/10 to 8, 9, or 10/10 is probably not possible. If it’s a slow rise, however, you may be able to avert it from getting to those high numbers, but if you’re like I was, it was usually zero to 10 in a millesecond.

So I came up with a plan that I call the S.T.A.R. Plan©. My S.T.A.R. Plan was inspired by the writers of “Coping Cat” and “The Cat Project” who came up with a “F.E.A.R.” plan for anxious children. It wasn’t quite right for emetophobia, but I loved the idea of a plan.

If you find yourself in a situation that triggers your emetophobia, it’s always good to have a plan. If you’re anything like I once was, your plan would be to get triggered, freak out and run. If you are triggered by your own nausea, however, it’s impossible to run, so you apply safety behaviours like asking for reassurance online or at home, or taking some stomach medication. This may help calm you down in the short-term, but as far as helping to treat your emetophobia for good, ass Dr. Phil might say, “How’s that workin’ for ya?”

S stands for “Scale” which refers to the 11-point scale that therapists use to determine how anxious you are. Zero means no anxiety at all, and 10 is the worst panic possible. When your emetophobia gets triggered, your anxiety will go up to one of the numbers on the scale. If you want to get better, it’s important for you to know what number you’re at. Sometimes you may become so anxious that you forget the S.T.A.R. plan, so it’s good to have a support person remind you by asking “what number are you at?”

T stands for “Tolerate.” The best way to get over a phobia is to stay in the situation and tolerate the anxiety without doing anything or thinking anything to make it go away. Different people are able to tolerate different levels (0-10) of anxiety. Your ability to tolerate the anxiety may also be dependent upon how quickly the number went up. If you can tolerate it, great. If not – move on to the “A.”

A stands for “Action.” If you can’t tolerate the anxiety, you can ask yourself “what actions could I take to bring down my anxiety?” These actions require learning and practice, which is the topic of another blog, but basically here are four actions that should help (They spell “BRIT”):

  • Breathe slowly and deeply. Slow is more important than deep.
  • Relax the major muscle groups in your body, head to toe. Relax your body. Try doubling your relaxation, then doubling again.
  • Imagine yourself in a safe, peaceful place if you can.
  • Think. I teach my clients to come up with a “mantra” of sorts to say to themselves. Mine was “You’re not in any danger,” but there are many more that my clients have come up with over the years. My favourite is “Vomiting is not dangerous or harmful. It can’t hurt me, so I don’t need to be afraid of it.”

R stands for “Repeat.” So all you have to do is go back to the beginning (the “S”) and ask yourself what number on the Scale of 0-10 are you at now? Most of the time you’ll find that your anxiety has gone down a point or two. So maybe you can Tolerate it now. If not, keep going through the S.T.A.R. plan until your anxiety is low enough to tolerate. Good luck!

Exposure Therapy

I’ve been “talking” with emetophobia folks online since 2000. Over these twenty years I’ve seen more people misinformed about what exposure therapy is than I’ve seen people who’ve tried it. It’s probably better to start off with what exposure therapy is not.

Exposure therapy is not just randomly running into a situation that exposes you to someone vomiting, or you, yourself feeling very ill. Yes, if you go to a birthday party and a kid is suddenly sick in front of you then I suppose you have been exposed to what you fear most. But the “therapy” part is missing. Therapy comes from the root word for “healing” and just randomly being exposed to vomiting and having the bejeezus scared out of you does nothing for your healing. In fact, it may make your phobia worse by re-traumatizing you.

For exposure to be therapeutic, it has to be structured. If you go to a CBT (Cognitive Behavioural Therapy) therapist they will normally build a hierarchy with you. Since this is difficult for most emetophobics to do, I have a good hierarchy that works for pretty much everyone right here on my website under “Resources” – “Exposure.” The current literature on anxiety and exposure therapy says that a list is as good as a hierarchy anyway. So you make a list of everything that frightens you. Or go to my website exposure section. Then you would normally begin with the least frightening thing, and progress slowly to the most frightening (which is normally watching explicit videos, hearing sounds or mixing up something that looks and smells like vomit).

Seriously. Don’t freak out. The final, most difficult steps ALWAYS seem impossible when you’re just starting out. But that’s the beauty of exposure therapy – it begins with something SO EASY and you go SO GRADUALLY that by the time you get to the difficult stuff, you hardly notice. Think of it like this: you’ve fallen down a hole, are terrified and you can’t get out. Then you notice there are a set of steps to climb up to get out. If you go one step at a time it’s easy to get up and out, but if you just look at the top step and think “I can’t possibly get up there” then you may not even try to take that first step. You’ll just sit at the bottom in the hole and cry. I did that for about thirty years.

The first steps in my online hierarchy are as simple as looking at the word “vomit.” There. You just did it. You may not have liked it, but you’re ok right now, ya? Then we look at some other words. If those are too difficult then we might just begin by imagining a scene where you’d be a little afraid.

In addition to the exposure resources I have online, I get all my clients to make a list of everything they avoid and all the safety behaviours they have. An example of an avoidance behaviour is perhaps not making medical appointments. An example of a safety behaviour is feeling nauseous and taking ginger or mints.

I usually wait until we’ve looked at all the words and drawings and cartoons and pictures and then have my clients begin to approach things they previously avoided, and/or stop using a safety behaviour. I assign this work as homework and check in each week. Then at the next session we begin looking at videos, which also start with simple things like a baby spitting up.

It’s not enough to just look through all my exposure resources to prove that you “can.” Anyone can white-knuckle it through the list and then feel great relief that the exercise is over. Your phobia will not improve. In fact, it will make your phobia worse to do that because the part of your brain that’s giving you all the trouble will say, “Wow, it sure feels good NOT to looking at that stuff now. To continue feeling good, I’ll avoid it forever.”

At each stage of the exposure, you must look at an item, record your fear level 0-10, and then either try to tolerate the fear level (if it is below 7) while still looking at the picture or use previously-learned skills to bring the number down below 7 where it can be tolerated. So you keep looking at the item until you are no longer afraid.

Sometimes if clients are recording rather low numbers for a few pictures in a row, I ask them to purposely raise their anxiety level. This ensures that the client is not “white-knuckling” their way through the pictures.

So….is it scary? The answer is yes, a little. But normally my clients’ anxiety levels only go up to about 5, maximum. That’s how I like to work with people. It’s a little scary, but it can be tolerated. Before long, they come to realize that all anxiety can be tolerated with a little practice.

Sex and emetophobia

It wasn’t until a client once asked me if it were ok to talk about sex that I started to think about sex and emetophobia. I reassured them that they can talk to me about absolutely anything. One might think that we 60-something grandmas don’t know much about the subject except for the missionary position in a long flannel nightie, but let me revamp our image for you: we went to college in the 70s. THE SEVENTIES. All the girls were on birth control pills, and there wasn’t any disease you could catch from a partner except gonorrhoea, which if you were so unfortunate, could be cleared up with one dose of penicillin. The good old days before herpes and HIV. Imagine it.

My first counselling gig was at the University of Waterloo “Peer Counselling Centre” in 1976. With some good, solid training, we volunteered a few hours a week talking to our peers about sex, birth control, abortion, being gay, being born in the wrong gender. Yes, 44 YEARS later we’re still talking about that.

But I digress. Emetophobics actually have a few things to worry about when it comes to sex, especially with some of the latest activities that many couples enjoy. What’s worse is that they’re often afraid to share these fears with their sexual partner.

I’ll try to be crystal clear, so you may want to read this blog in private.

Oral sex

Oral sex can present a problem to either male or female emetophobes. For the (straight) female or gay male the possibility of gagging on either the penis or the ejaculate can be terrifying. Men can become equally terrified of their partner gagging and even vomiting during oral sex. There are some emetophobic queer women who are quite reluctant to perform oral sex on another woman.

anal sex

Considering that Norovirus particles are contained in fecal matter, anal sex can be daunting whether one is the giver or the receiver. The problem is that the penis (or sex toy) is removed, theoretically contaminated. And then what do you/they do with it? We all know it’s not getting near your mouth anytime this century. But does he know that?

anilingus

Yep. I had to look that one up. Thanks to a comedy routine by Chris Rock, I heard it was called “tossing his salad.” Apparently there are a plethora of other terms. Suffice it to say that your average emetophobic would not be caught dead doing this one, which involves your tongue and your partner’s anus.

anal-digital stimulation

What’s he going to do with that hand now?

the solution

This may seem ridiculously simple, but you have to talk to your partner about the kind of things you like to do, and what you feel uncomfortable with. If you’re afraid to do just about everything, and your partner really wants to be adventurous then perhaps they aren’t the right partner for you. But if you’re already married to them, then there needs to be some give and take. Explain what frightens you. It’s easy enough for him not to push his penis too far into your mouth, and to let you know when he’s about to ejaculate. If they want anal sex, you might have to negotiate a shower afterward before doing anything else. You get the idea. Talk. If you can’t talk to someone with whom you’ve taken off all your clothes, then who can you talk to?

The other, perhaps more obvious solution, is to get treatment for your emetophobia. It really is treatable, and you don’t need to be afraid of the many things in life that non-emetophobics enjoy forever.

Best of luck, and remember that you can discuss anything with your therapist if need be.

The Dreaded Colonoscopy

Often I work with clients who have gastro-intestinal issues. Their doctors almost always recommend a colonoscopy. It’s a simple procedure done under heavy sedation (you’re usually totally asleep, but not under general anesthetic). Most emetophobics aren’t too worried about the procedure; they’re just terribly worried about the prep the day before. Since it’s important that your whole colon is clean as a whistle, you’re usually told to eat no fibre for a day or two, then have only clear fluids the next day, and then drink some form of powerful laxative to clean out your colon. Yes, it’s a day of diarrhea, but it beats paying for one of those “colon cleanses” at a spa, since it’s the same thing and generally paid for by your insurance or medical system. And of course it’s waaaaaay better than getting colon cancer! I myself have had several of these procedures and I don’t mind them at all anymore. Then again I don’t have emetophobia anymore so maybe that doesn’t count.

So why is it “dreaded?” Well, emetophobics worry that drinking the laxative will make them sick. Even though I’ve never talked to a single emetophobic who ever got sick from it. Some folks who have very weak stomachs and are NOT afraid of vomiting report getting sick from it. These people are not you guys! Emetophobics can control vomiting at the worst of times, and this is not the worst of times.

One of my clients, Jessica, has gone through several colonoscopies when she was very phobic, and she was kind enough to write a short post about it. So here it is:

“Three years ago I had whittled down to 100 pounds after being nauseous and having an upset stomach for seven months (an emetophobic’s worst nightmare). I finally got an appointment with a GI doctor who suspected Crohn’s Disease from my symptoms. When he mentioned the colonoscopy procedure to confirm, my chest tightened and heart stopped. How was I ever going to drink all the liquid to prep for it? What if it made me sick? I had only ever heard how terrible prepping for one was.

I made a decision. I immediately went into fight mode, toughened up, and decided to just do it. I surprised myself when it was way easier than I imagined. I was instructed to drink 64 ounces (2 litres) of Gatorade mixed with the prep medicine. To make it easier, I drank the prep/Gatorade mix with a straw over ice. I stayed calm, stayed distracted, and reminded myself it was a temporary discomfort for a healthier me. I watched a tv show and played Yahtzee with my family.

The next morning I went to the hospital, and completed the colonoscopy under general anesthetic. I woke up next to my husband and nurse. My doctor made sure I stayed comfortable in the recovery room as well. They offered me anti nausea medicine for when I was coming out of the anesthesia and warm blankets for my feet. Once I was home, it was like nothing had ever happened. I’ve had two colonoscopies in the last three years and when it comes time for my next one, I will be excited for the best nap I’ve ever had.

Nothing is as ever bad as our heads tell us it is.”

Anna’s notes: 1) Most colonoscopies are not performed under general anesthetic anymore, but rather “conscious sedation.” There’s no nausea afterward. 2) The prep mixtures are getting way better with every passing year. For my last one, I only had to drink a small bottle (less than a cup) of lemon-flavoured liquid the night before and another one the morning of. 3) Jessica met with me for about 14 sessions and is doing great! Thank you, Jessica, for submitting this for me!

coronavirus and emetophobia

Edit: August 7, 2020. Wear a mask over your nose and mouth. Don’t touch it except to put it on and take it off. If you have to go out, try to keep 2 metres away from other people, even if they’re wearing masks. Don’t congregate in groups larger than 10, and be sure to know everyone in the group or have some contact info for them. Get tested if you show any symptoms at all.

Edit: March 12, 2020. “Cancel Everything” – don’t go out unnecessarily to places where there are a lot of people. Avoid travel. Protect the elderly. End edit.

When Coronavirus was first publicized in January, many of the Facebook pages and chat sites for emetophobia carried the same message: “I’m not afraid of it, because none of the symptoms is vomiting.” In other words, if you’re only afraid of vomiting and not of dying then you’re good. If truth be known, emetophobic people are also afraid of dying – they just don’t realize it. Vomiting=dying in some part of the emetophobic brain. Other forms of dying we feel pretty much immune to, even though there is risk involved. Phobics are naturally unwilling to take any amount of risk as it relates to the thing they fear, even though they’re quite willing to get into an automobile every day.

I was hoping that the conversation might be a bit more realistic, which it has now become: we germ phobics have something to teach the rest of the world – good hygiene! Wash your hands well, and don’t touch your face, meaning the “T-zone” of eyes, nose, mouth. Those are the mucus membranes just waiting for the virus to find its entry point.

With norovirus, touching one’s nose is less likely to infect you, and touching the eyes even less, as norovirus must be “swallowed,” meaning vomit or fecal matter has to make its way to your stomach and intestines. Ew. Coronavirus, on the other hand, just needs to make its way, via your mucus membranes, to your lungs. Gah!

Wearing a mask may help you to remember not to touch your mouth or nose, but as masks are in high demand just now it’s better to leave those for folks who are actually sick. That way, their sneezes and coughs can’t infect anyone else. Gloves are pretty useless because, just like hands, they touch everything and are quickly covered in germs.

Click here to link to a great Washington Post article that talks about the psychology of why refraining to touch our faces is so difficult.

Six Degrees of Separation

There’s a running joke in Hollywood that there are only ever six degrees of separation from any actor to Kevin Bacon. If you’re a real movie buff you can play the game with your friends and try to figure it out.

The Kevin Bacon game works pretty much with any actor, as it’s based on the idea that there are only six degrees of separation from any one person to another on the planet. It got me to thinking…

I find that a lot of my emetophobia clients who have a fear of vomiting worry extensively (some much more than others) about the degrees of separation of Norovirus (aka “stomach flu” or “stomach bug”)[1]. What I mean by this is they’re afraid that someone with Norovirus touched this, then that, then what if I touch this, then, that – is “that” contaminated with Norovirus? Here’s an example of what I mean:

  1. Bob has Norovirus
  2. Bob doesn’t wash his hands after using the bathroom. There are Norovirus particles on his hands
  3. Bob opens the door
  4. Bob picks up his keys
  5. Bob opens his car door
  6. Bob drives to the grocery store
  7. Bob gets a grocery cart
  8. Bob grabs a box of granola bars, reads the label, then puts it back.
  9. A few moments later I grab the granola bars and put them in my cart. I buy them and they get put in a bag
  10. I touch the bag handles
  11. I touch my purse handles and keys
  12. I eat a burger without washing my hands
  13. I will get Norovirus.

I now believe that I must wash my hands, my purse handles, and wipe everything item of my groceries or I will catch Norovirus.

Here’s the thing: you won’t. Norovirus is very contagious, true, but what we have here are TWELVE degrees of separation from the Norovirus particles and you. That’s way too many for the virus to still be active. Here’s what can happen at the grocery store:

  1. A kid has Norovirus
  2. The kid doesn’t wash his hands after using the bathroom.
  3. He touches nothing until the grocery cart handle.
  4. You use the cart next and touch the handle.
  5. You put your fingers in your mouth or eat a burger.
  6. You get Norovirus

That’s six, right? So yes – you could get Norovirus this way. But NOT IF THERE ARE ANY MORE THAN SIX. Because I’m actually talking about one item touched by the kid, touched by you (the grocery cart), and I’m also talking about invisible Norovirus particles, not visible poo. Ew. Sorry for that. This is why there are wipes in grocery stores now, for your cart handles.

Here are the items you don’t want to touch, then put your hand in your mouth:

  1. Anything in someone else’s bathroom, or yours if someone in your house has Norovirus: toilet flusher, taps, soap dispenser, paper towel dispenser, countertops, cups, toothbrushes, toiletries or makeup, door handles.
  2. Doorknobs
  3. Other people’s phones (your phone is fine)
  4. Light switches (especially in bathrooms)
  5. Elevator buttons
  6. Gas pumps
  7. Other people’s hands

 For all you emetophobia folks out there, let’s review how you might catch Norovirus:

  1. Someone with Norovirus throws up within ten feet of you. That’s about the radius that the aerosolized particles can travel, although it’s more like seven feet to the side. (Now you know why it’s so contagious in schools.)
  2. Diarrhea in a toilet can become aerosolized when the toilet is flushed. It can land on toothbrushes across a room.
  3. Someone in the food production business doesn’t wash hands and touches your salad or hamburger bun.
  4. You touch something from the list, above, don’t wash your hands, then put your hands in your mouth. You could theoretically catch it from putting your finger in your nose, but it’s highly unlikely, and even more unlikely you’d catch it from touching your eye. Zero chance from touching your face.

There is more information on the Norovirus page of my website including myths about how it is caught. The truth is, most Norovirus is spread by children. They suck at handwashing. Apparently so do caregivers in nursing homes.

The good news is that it’s really easy to get the virus off your hands – you just wash them with plain soap and water. Emetophobia folks will tell you about all the things that kill Norovirus, but if you wash your hands before putting them in your mouth you really don’t need to worry.


[1] Noroviruses are neither a “flu” nor a “bug” – those are just sayings.