Why can’t I burp?

Inability to burp is a medical condition known as retrograde cricopharyngeus dysfunction (R-CPD). According to one of my clients who suffers with this condition, many folks with R-CPD are also emetophobic. I’m not sure what the connection is, but I can well imagine how uncomfortable it makes you feel to have trapped gas in your stomach, bloating and painful gas in your colon. Never mind that your incidence of flatulence (farting) would be much higher than the average person.

People with R-CPD have a type of deformity in their upper esophageal sphincter, which cannot relax so as to release the air bubbles. When we eat or drink, that sphincter muscle relaxes for a second. It’s also supposed to relax in order to burp.

Every once in a while I’ve felt like I can’t burp when I need to, and it’s not a nice feeling at all. Sometimes it can even be painful. For those of you with children, remember the lengths we would go to in order for our newborn to burp after feeding for a few minutes? Patting or rubbing (or downright pounding on) the back, sitting baby up, laying him down then sitting him up, putting her over our knee on her stomach and on and on it goes. If you don’t get the burp up, you’ll pay for it a few hours later (well, technically the baby will pay for it with extreme discomfort, but you’re the one enduring hours of screaming).

Some people with R-CPD experience nausea, hypersalivation, really bad hiccups, difficulty breathing and excessive flatulence. Much like emetophobia, people with R-CPD are often misdiagnosed as having IBS or acid reflux, but the treatments for these don’t help. If you think that you’re actually suffering from R-CPD, you need to get a formal diagnosis from a gastroenterologist. The best way to do this is to have the doctor look down your throat (esophagoscopy) or do a swallow study.

Once diagnosed, there is a treatment that can help. Botox is injected into the sphincter muscle which weakens it for a few months. This may eliminate the problem or at least make it much better. After this treatment, you can burp and keep practicing burping so that when the Botox wears off you’re still able to do it. Some people with less severe R-CPD can learn to burp without the Botox and after a lot of practice they can do it well enough to eliminate the problem.

Emetophobics with R-CPD will feel much relief once they receive treatment. Burping will help diminish their feelings of nausea and bloating which can be very triggering of anxiety.

For more information, visit https://laryngopedia.com/

I’m Afraid to Get Better

I’ve had many clients over the years gingerly tell me that at least part of them is afraid to get over the emetophobia. I know their reasoning before I even ask. “You’re afraid that if you get better, you won’t be so careful, and you’ll end up getting sick.” 

“Yes.”

Most of them understand that this doesn’t make sense, but many do not. Either way, they’ve been embarrassed to tell me. I blame a lot of it on other therapists who have been judgmental of them in the past when they’ve come in for emetophobia treatment. In fact, many therapists who don’t understand emetophobia or how to treat it have told their clients that they just don’t want to get better. They usually conclude this when they can’t think of what to do with these clients that to help them. 

Sometimes the refrain is picked up by parents who are also at their wits’ end about what to do with an emetophobic child who doesn’t want to eat, drink, go to school or go to therapy. They conclude that the child/teenager doesn’t want to get better or is afraid to get better so they’re not “trying.” 

I do get it. I remember at least thinking that I might be afraid to get better when I had emetophobia. Yet I desperately wanted to get better. I knew it wasn’t logical – after all, if you get better that means you’re not afraid anymore, so whether you’re “careful” or not, it really doesn’t matter if you get sick because you’re not afraid of it anyway. That may have been too confusing a sentence. Sorry! Think of it this way: a person has a severe phobia of puppies. Especially those fluffy, bouncy, slobbery Golden Retriever puppies. Ya, these guys:

Yes, there are many people terrified of them. They have panic attacks just like you, and they do everything they can to avoid going anywhere where they might see one, and they never watch Disney movies and close their eyes during most TV commercials. If one of these phobics accidentally stumbled on this page they’d be crying right now from seeing that picture. Don’t even say in your head that you think it’s ridiculous!!!! These things aren’t logical, as you well know. 

Okay, so now imagine that someone who has a phobia of puppies comes to me for treatment. On intake, they whisper gingerly that they’re afraid to get over the phobia because if they do, they might end up not caring any more and then they’ll just go get a puppy some day. 

Did that make you scratch your head? But it’s the same thing, right? EVERYONE with a phobia is afraid to get better in case they stop being “careful” to avoid what they fear. What if someone gets over their spider phobia and just throws caution to the wind and starts gardening? What if someone with a clown phobia gets better and just starts going to kids’ birthday parties? You’re getting the idea, right? And yes, I know that if you’d rather be afraid of puppies or clowns or even spiders for that matter right about now.

So first of all, the obvious: if you don’t have emetophobia you won’t care if you get sick, or risk getting sick because you won’t be afraid of vomiting anyway. But secondly, and I speak from experience here, you’re not going to just let all hell break loose and start licking the bottom of your shoes or your fingers after shaking hands with sick people or whatever. I’m no longer afraid of vomiting but I sure as heck don’t like it. I might risk eating something that seems wonderful if I’m not sure about it or who cooked it, but I don’t want Norovirus – I had it ten years ago and it wasn’t very nice: the worst part for me was the fever, chills, exhaustion and body aches. So even though I don’t fear vomiting any more, I still wash my hands before I eat and I don’t put my fingers in my mouth or nose unless I’ve just washed my hands thoroughly for 20 seconds and not left my living room.

Get better, ok? Don’t be afraid of it! Getting better is awesome.

Safety Behaviours

Do Safety Behaviours Work?

Along with avoidance of the feared stimulus (nausea, someone else saying they feel or were sick, seeing something associated with vomiting), a safety behaviour is something that you actively do to avoid vomiting at all costs. Some examples of typical safety behaviours are:

  • Sucking on mints
  • Taking ginger (candies, tablets, tea)
  • Drinking ginger ale or another fizzy drink
  • Sipping water
  • Chewing gum
  • Sniffing peppermint or eucalyptus essential oils
  • Taking an OTC stomach medication such as Gravol (Dramamine), Pepto Bismal, Divol, Tums,
  • Taking a prescription anti-emetic such as Ondansetron (Zophran)
  • Taking a prescribed “Rescue Medication” tranquilizer such as Xanax, Ativan
  • Taking prescribed stomach medications such as Omeprazole
  • Carrying a plastic bag in your purse or pocket at all times
  • Carrying a “safety kit” with any of the above items with you at all times
  • Wearing a face mask before Covid-19
  • Washing hands, changing clothes, showering
  • Opening doors or pressing buttons with your sleeve
  • Checking “best by” dates on food
  • Drinking alcohol, smoking marijuana, taking illegal drugs
  • Asking someone for reassurance, when you know what they’ll say every time
  • Practicing large muscle relaxation and/or slow breathing not to calm down, but so you won’t vomit
  • Needing to be with or talk to a “support” person when anxious/nauseous.

How many of these can you relate to? Are they helpful or do they work? Well, what if I told you that they most certainly don’t work and that you should really try to slowly give every one of them up? I imagine that might make you very anxious. Without working with a therapist, it might be difficult to give these up on your own. It is the same with avoidance behaviours – stopping them is really difficult without some sort of professional help. Nevertheless, there are determined people out there who are reading this right now who can do it if they try!

So, do safety behaviours work? The answer is yes and no. Yes, they make you feel better in the moment. They calm you down. Some of them most certainly prevent vomiting although the odds of you vomiting without them are pretty slim anyway. But no, they don’t work to lessen your anxiety and in fact most of them will make your anxiety worse over time. So the more you use these behaviours the worse your phobia will get. Let’s look at why that is.

Engaging a safety behaviour presupposes the wrong thing: that the problem is vomiting. I’m sure it will surprise many of you to hear that vomiting is not the problem. Vomiting is normal, natural and neutral. It isn’t dangerous or harmful. It can’t hurt you, so there’s no need to avoid it or fear it. (I know that’s not what you actually think right now; I’m just pointing out the logic.) The problem is anxiety. Your anxiety around vomiting is what’s not normal. It’s way out of whack for what vomiting is – just a yukky, unpleasant thing that nobody likes. There are many of these things in the world: diarrhea, Pap tests, proctology exams, colonoscopies, doing your income tax, picking up dog poop, flossing your teeth. None of these is dangerous or harmful, but if the universe could eliminate any one of them we’d all be happy about it.

Anxiety/fear/terror should be reserved for dangerous things like alligators, grizzly bears, home invasions and nests of gigantic furry venomous spiders. It doesn’t have any place in the normal yet yukky things of life. Your emetophobic brain has somehow mixed up vomiting with all the other deadly things you need to be terrified of. So you avoid it at all costs and then come up with these safety behaviours to keep you “safe.” The thing is, you ARE safe, whether you vomit or not! But I know it doesn’t feel that way.

The road to recovery is long and hard with emetophobia. One important part of the journey, however, is slowly giving up your safety behaviours so your brain comes to realize that you’re just as safe without them as with them. You also need to slowly stop avoiding the things you’ve been avoiding. Either with a therapist or on your own, you also need to slowly change your thoughts from the catastrophic “OMG vomiting is horrible/terrible/awful/the worst thing ever” to something more normal such as what your non-emetophobic friends think about it (ask them, write down what they say, memorize it, replace your catastrophic thoughts with these thoughts every time you think them.) It will take time, but eventually it will work.

Once you come to realize that anxiety is your real problem, you can focus your energy on working on that, instead of on preventing vomiting. This will make your phobia better, which is really what you want.

There is a ton of information on this website that will help both you and your therapist get your anxiety under control!

Chemotherapy

Emetophobia and Chemotherapy

I took some liberties with the Halloween videos available on Canva this week – lol!

Pretty much since the birth of the internet I’ve been finding and talking to people with emetophobia. My first computer experience with internet was 1996, and by 1998 I discovered, after 39 years, that my phobia had a name and that there were other people like me! By the year 2000 I was a moderator of “emetophobia.org” – a discussion forum that quite quickly went to 10,000 members. There was no such thing as Facebook groups at that time. This website had so much traffic that you could go there any time of the day or night and find someone with whom you could talk. Thank goodness for time zones!

The great thing about a discussion forum (which still exists, by the way) is that topics can be organized into sections, and you can view the topics to see if you’d like to partake of that conversation. Now, Facebook groups have pretty much taken over the emetophobic community. Our latest podcast was about the pros and cons of social media support groups.

Despite changes in how emetophobics talk with one another online, there is always this question, “What would you do if you got cancer? How could you deal with chemotherapy?” Usually the responses are something to the tune of “I’d rather die.” Sound about right? It’s not.

I found the breast lump when I was just 37. My youngest of three children was only 11 years old. My world came crashing down, for a number of reasons only one of which was being freaked out about having to have chemotherapy. I had had some treatment, but I was still terrified of vomiting. I had always told myself that I would rather die than vomit, and thus I would rather die than take chemotherapy. I was serious about this. But let me tell you something: when death looks you right in the face, with a ghoulish sneer and an open door to utter darkness, you’ll take the chemo.

The reason we say we’d rather die than vomit is that our amygdala at the back of our brains is responsible for our survival and whenever it gets triggered it shouts out just one message: “Danger! You’re going to die!” With a phobia, for some reason the wiring in our brain isn’t just right and when we experience the phobic stimulus (nausea or someone else vomiting) our amygdala gets triggered. So we avoid vomiting at all costs, the way we avoid certain death. We believe that vomiting and death are pretty much equal and because we’re not faced with death we fear vomiting more. Avoiding death is pretty simple when you’re young and healthy.

But then actual death comes along. And suddenly they’re not equal anymore, and somewhere in our messed-up brains something clicks as if to say, “ok so vomiting isn’t really as bad as death and I sure don’t want to die.”

I went through surgery, chemo and radiation. The chemo was nowhere near as bad as they make it out to be on TV or in the movies. I only had to have chemo one time (four treatments, three weeks apart). I did get very tired and felt like hell for 2-3 days. They gave me a powerful anti-emetic – Ondansetron (Zofran) – at the time it was $30 a pill but I would have sold my cat, my dog and my TV set for it if I had to. I did not vomit. And this was in 1996 – they have much better, more efficient chemo now and a whole host of anti-emetics in addition to Ondansetron. They can give you a cocktail of about four or five of them at once if need be.

I never had a trace of cancer again. Since 1996 I’ve conquered my emetophobia, seen three children graduate university, watched my daughter dance on stage in Germany as a professional ballerina, held 7 grandchildren in my arms and loved each one like they were my own, celebrated 39 years with my husband, bought a beautiful house, been to Paris, had two wonderful and successful careers in which I helped a lot of people, published two books with a third on the way, and probably a thousand other things I never would have done if I’d said I’d rather die than have chemo. Trust me, life is so much better than death.

Avoiding norovirus: tips, Facts and myths

Trigger Warning: This blog may be very triggering to people with emetophobia, as vomiting is discussed in plain-speak. My hope is that it will reassure some emetophobic people so they can live a more normal life.

Norovirus is the scientific term for what has commonly been called “stomach flu,” “stomach bug,” “winter vomiting virus” and a few other terms. It’s short for “Norwalk-like viruses,” but it is neither a flu nor a bug. Norovirus causes several hours of nausea, vomiting and diarrhea. One may also have body aches, fatigue and a fever for up to 24 hours. All in all, it’s not very nice to have and nobody likes it. However in the grand scheme of things it’s harmless and over with quickly. The only thing you have to watch out for is that a child doesn’t get dehydrated, which can happen quickly and can be fatal if not attended to. Kids need to just have a few ice chips or a teaspoon of water and wait to see if they can keep it down. If not, keep trying and watch for signs of dehydration – they may need to go to a hospital for IV fluids. Adults can also get dehydrated. Sip water very very slowly and hold off on any water until you haven’t had vomiting for a couple of hours.

How contagious is Norovirus? Well, compared to Covid-19 which is airborne and you can catch by just breathing near a contagious person, it doesn’t seem so bad. Norovirus particles (virions) must be ingested (swallowed) in order to get you sick. This means that normally they enter through the mouth but sometimes the nose, and are sniffed back and swallowed. It is unlikely to ever get Norovirus through your eyes although it is theoretically possible (but your finger would have to be filthy). Sometimes Norovirus swirls through the air either when someone vomits in a room, or you flush a toilet without the lid being down. (I know, gross, eh?) You can pick up Norovirus particles on your hands when they settle on counters or doorknobs or a person with literally poop or vomit on their hand touches a knob or counter and then you touch it later and put your hand in your mouth. The particles stay active for about 9 days on surfaces that have not been cleaned, but just to be safe it’s good to think of surfaces as possibly contaminated for 14 days. Norovirus is present in saliva, but scientists don’t think it’s enough to make someone else sick through kissing or sharing utensils/cups – unless the sick person has just vomited and not washed out their mouth. You cannot catch Norovirus by having sex, or through the bloodstream, or on a toilet seat, or by sitting on an airplane and definitely not by breathing the air near a sick person. Unfortunately one of the ways people catch Norovirus is through food that has been handled by a sick worker (who hasn’t washed their hands) and the food is not cooked fully.

Norovirus is killed at 65C or 150F. This is a little hotter than food is normally kept in a restaurant (60C is all that’s required) and for water, too hot to put your hand in. However it is nowhere near boiling (100C or 212F). Check the manual of your washing machine and dryer to see how hot they get on their hot cycles. If it isn’t high enough, you’ll have to add bleach to the wash to kill off the Norovirus on your laundry. Diluted bleach is cheap and easy to find, and perfect for cleaning up if someone in your house is sick. Google how much bleach you need for porous surfaces, non-porous, laundry, etc. There’s lots of great info out there but don’t go crazy by using straight bleach or way too much bleach. You can literally make people sick doing that. Carpets must be cleaned with a steam-cleaner as you can’t bleach them. Keep contaminated sheets, clothing and underwear of sick people separate from other laundry for 2 weeks.

Washing hands with plain soap and water is the best way to get rid of Norovirus on your hands. You don’t need to scrub or go crazy – just 20 seconds washing all the areas of hands and wrists, then rinse off. Hand sanitizers are not as effective as plain soap and water. Some hand sanitizers don’t kill Norovirus (eg. alcohol-based). If you find one that has benzalkonium chloride, that will work but you have to leave it on for a minute or two. Again, Google will tell you if your hand sanitizer works for Norovirus.

One of the more common ways to catch Norovirus is through food, unfortunately. In fact, 70% of “food poisoning” is actually Norovirus and there was nothing wrong with the food. If you’re worried about your restaurant food, order takeout and microwave it to above 65C (use a food thermometer so you don’t go crazy and burn the food). Skip the salads.

Wearing a mask is a great way to prevent not only Covid-19 but Norovirus as well. They work because they keep your hands away from your mouth and nose. You can’t breathe Norovirus in, remember, but that mask will remind you not to touch your mouth or nose unless you’ve washed your hands. This method works great for kids as well.

The incubation period for Norovirus is 24-48 hours. Depending on how much viral load you’ve ingested, you will get sick either sooner or later. Some folks have even become ill before 24 hours. Norovirus has a “sudden onset” of symptoms. This means that you could feel increasing nausea for about an hour, maybe two, during which time you may have diarrhea that is like water (simply having soft stool is not indicative of Norovirus). Sudden onset does not mean that you’re fine one minute and vomiting the next. You’ll have plenty time to figure it out, get home from work, etc.

People are contagious from the time they begin to get sick until about 2 weeks after. They’re only contagious after because the Norovirus is shed in their stool. So if you trust someone to wash their hands after using the bathroom, then they’re not contagious at all. You can visit someone’s house if they’ve just gotten over Norovirus. Just don’t put your hands in your mouth or nose until you get home and wash them. Kids aren’t great at wiping bums or washing hands, so kids do carry a lot of Norovirus around and it spreads in schools. Many people in nursing homes are in diapers, and staff don’t use full PPE when changing diapers so they can easily spread the virus to others in the nursing home. Perhaps now that PPE is required for Covid, we will see less spread of Norovirus in nursing homes. That would be great.

It’s also great that people are wearing masks AND washing hands a lot more, and a lot more thoroughly. Scientists are also working on a Norovirus vaccine, which has proven tricky because the virus mutates during the year and so far would require 1 or 2 boosters every season. I know people with emetophobia would jump at that, but most people wouldn’t and vaccines like everything else have to be economical and practical.

You cannot catch Norovirus from your cat, nor can you give it to your cat. Dogs can carry it only if they’ve come into contact with the vomit or feces of an infected person. Oysters may contain Norovirus and if you eat them raw, you’re rolling the dice. You cannot get Norovirus from tap water.

For more tips, myths, information and cleaning solutions, check the websites below.


  1. References
  2. Burrell, Christopher J et al. Caliciviruses, in Fenner and White’s Medical Virology (Fifth Edition), 2017
  3. Cates, J.E., Vinjé, J., Parashar, U., Hall, A.J., 2020. Recent advances in human norovirus
  4. research and implications for candidate vaccines. Expert Rev. Vaccines 0, 1–10.

Centers for Disease Control and Prevention

de Graaf, M., van Beek, J., Koopmans, M.P.G., 2016. Human norovirus transmission and
evolution in a changing world. Nat. Rev. Microbiol. 14, 421–433.

Estes, M.K., Ettayebi, K., Tenge, V.R., Murakami, K., Karandikar, U., Lin, S.-C., Ayyar,
B.V., Cortes-Penfield, N.W., Haga, K., Neill, F.H., Opekun, A.R., Broughman, J.R.,
Zeng, X.-L., Blutt, S.E., Crawford, S.E., Ramani, S., Graham, D.Y., Atmar, R.L., 2019.
Human Norovirus cultivation in nontransformed stem cell-derived human intestinal
enteroid cultures: success and challenges. Viruses 11, 638.

Foodborne Disease Burden Epidemiology Reference Group. 2015. WHO estimates of the global burden of foodborne diseases. World Health Organization – World Health Organization, Geneva, Switzerland, 2019

  1. Garza, Jose M., Cohen, Mitchell, B. Infectious Diarrhea, in Pediatric Gastrointestinal and Liver Disease (Fourth Edition), 2011

Green, K. Y., Noroviruses and Sapovirus, in Encyclopedia of Virology (Third Edition), 2008

Yates, Marylynn, Norovirus, in Microbiology of Waterborne Diseases (Second Edition), 2014

Can Imagination Be An Emetophobia Treatment?

What if just imagining the threat of vomiting gave you the same fearful feelings as actually doing it? Well, first of all, that sounds pretty scary. We go through enough anxiety from the fear of vomiting without adding to it by imagining it! So it’s not something anyone would do in their spare time. However, in the safe setting of a therapy appointment for emetophobia treatment, perhaps it could be quite useful.

Think about it for a moment. If you have a fear of, let’s say, puppies (yes, it’s a real thing), then all I need to do is put a puppy in a crate at the end of the hallway. For gradual exposure, you just need to inch closer and closer to the crate until you can finally touch the crate, unlock the door, reach your hand in a for a moment, etc. Ah….how divine would it be to have a phobia of puppies, eh? Because once you’ve received treatment and you’re over your phobia what do you get? A PUPPY! A WARM, FURRY, LICKY, CUDDLY, JUMPY, TAIL-WAGGY, ADORABLE PUPPY!!!

What do WE get? *sigh*  We get to throw up. Whoop dee doo.

Anyway, back to the main point. We can’t put ourselves vomiting at the end of the hall in a crate and slowly approach it. So we therapists have to get very creative. Some therapists think that an acceptable emetophobia treatment would be to just make yourself vomit. They used to sell something called syrup of ipecac in drug stores. You were meant to buy it and have it in your cupboard at home in case your kid swallowed some sort of poison so you could give it to them and induce vomiting. They don’t recommend this now, as many things that a kid could swallow would harm them more if they vomited. They don’t even sell it at all here in Canada – it’s not even on Amazon. Anyway, it’s a terrible idea to drink ipecac or use any other method to vomit on purpose. Some therapists want you to stick your finger down your throat like the bulimics do. Terrible idea. It’s like having a gigantic rabid Pitbull at the end of the hallway, and not in a crate. Therapists aren’t very creative if they can’t think of any other way to treat emetophobia than to make their clients sick. All healthcare providers should remember the jist of the Hippocratic Oath: first, do no harm

So what are we left with, then? Well, there are pictures and sounds and videos and those help, but there is also the idea that you can work with clients in their imaginations and/or memories. And the good news is that there is a good amount of science behind it. The latest study (December, 2018), relating to anxiety disorders, just came out of the University of Colorado Boulder and Icahn School of Medicine researchers.[1] These folks got 68 people to hear a sound an experience a mildly unpleasant shock. They then divided everyone into three groups. The first group heard the sound, but didn’t receive the shock. The second group imagined the sound, but didn’t receive the shock, and the third group imagined sounds of birds and rain falling. 

The results were pretty amazing. In the first group who heard the sound with no shock, eventually they desensitized to the sound. Enough times without the shock and the sound didn’t bother them anymore. The amazing part is the second group who just imagined the sound – they also were initially “fearful” but then the more they imagined the sound, the less afraid they were of it. And their brains showed the same parts “lighting up” on the fMRI.

This has great consequences for phobia therapy. Imagination can be a powerful tool. It can be used in a few ways:

  1. The client can imagine vomiting, rather than having to experience it.
  2. The client can imagine a calm, peaceful place as part of an overall strategy to calm the body. Apparently imagining the beach and being there are the same thing to many parts/systems in your brain!
  3. Clients can imagine something they fear, and further imagine coping with it well, rather than avoiding, using safety behaviours or refusing to take part in the exposure. Sports psychology uses this theory all the time: imagine making the shot, the goal, the swing. Work it out in imagination first, then execute it.

Meanwhile, I’m going to go imagine I’m eating a peanut-butter-cup Blizzard from Dairy Queen so I don’t gain any more Covid pounds!


[1] Reddan et al., 2018, Neuron 100, 994-1005.