America the Beautiful

I am Canadian – 6th generation. My ancestors were among the first United Empire Loyalists to land in Nova Scotia from Britain in the late 1700s. Among my ancestors is also a First Nation’s woman of the Mi’kmaq tribes of eastern Canada. My family history does not record her name.

In 1925 my grandmother wished to divorce my grandfather for “physical cruelty” but women were not allowed to divorce men for any reason, although a man could divorce a woman for adultery. So grandma packed up a horse and cart with five children and rode all the way to Boston, Massachusetts where she settled for several years until she became a citizen and divorce her husband, as this was allowed in America. After the divorce she returned to Nova Scotia with her two youngest children: one was my mother, age 9.

So I have two aunts and an uncle in Boston, who were much beloved of mine in my childhood. We went to see them every year, often taking my Aunt Sadie with us to Nova Scotia to visit my grandparents. I also have several cousins in Indiana to whom I’m very close. Most of my clients are from the United States.

Needless to say, yesterday was a particularly painful day for all of us who love America – those living there and those who have relatives, friends and much-loved aquaintances – on “both sides of the aisle” as American politicians say. I thought for my blog this week I would just share with you the second verse of a very familiar song. Comments have been turned off.

O beautiful for pilgrim feet,
Whose stern, impassioned stress
A thoroughfare for freedom beat
Across the wilderness!
America! America!
God mend thine every flaw,
Confirm thy soul in self-control,
Thy liberty in law!1

_______________________________________________

  1. Katherine Lee Bates, 1893.

Kids and Emetophobia

The most important thing to remember is counter-intuitive to parenthood: don’t reassure the child if they ask questions. Reassurance, when it comes to anxiety disorders, is a real no-no. It’s called a “safety behaviour” and it makes the phobia worse. Think about it like this: if a child asks whether or not you think they might be sick, and you reassure them they won’t be, then the child feels better/calmer. So the kid’s brain goes “wow – I feel so much better when I’m reassured – I’ll ask for reassurance a lot now.” Reassurance also subconsciously tells the child that vomiting really is dangerous.

So if the child asks “will I be sick?” answer honestly: “I don’t know.” Shrug it off like it’s nothing. If you’ve been offering reassurance up until now, the child is going to freak out. That’s ok. Their freak-out won’t last forever. Remain calm – don’t get angry – just explain to them that nobody knows when somebody else will throw up, and besides it won’t hurt you – it’s just yucky and nobody likes it. Be completely nonchalant like it’s not a big deal (because it isn’t)!

I can’t possibly write everything you need to know about kids and emetophobia in one blog, so I’ll try to hit the highlights and give you a few tips to save your sanity. First of all, the best thing you can do is to order the Turnaround Anxiety Program (associate link) along with the Emetophobia Supplement of which I am an editor. It’s written by Chris McCarthy and my good friend and writing partner Dr. David Russ. David and I are busy writing a book to help therapists treat emetophobia. Anyway, check it out!

Very young kids are naturally afraid of vomiting. Unless they’ve been vomiting steadily since a baby, they may not experience it again until they’re two or three at which time they must wonder what the hell is wrong with the universe that this can happen! Parents normally comfort them and tell them that they’ll be ok. They teach them to vomit in the toilet or in a bowl/bin/bucket (the three B’s of not-on-the-carpet). If nothing else happens in that child’s life they may just forget about it, or tell you the next time how much they hate it. However, if there’s any kind of stressor (even a “good” stressor like a new baby or a new room/house) then they can start to channel all their anxiety in vomiting’s direction. You may not be able to identify the stressor but that’s ok because the treatment is the same anyway.

Reassurance-seeking can be tricky. They may ask “is it ok to eat this?” “do you think I’ll have a good day today” or “do I look pale to you?” and other such sneaky questions. Be suspicious of all questions. If repetitive questions are asked, explain to the child that you will answer any question only once. Use the Perry Mason, “asked and answered!” if you have to.

Without reassurance from parents (and clue in the teachers as well), the child will need some strategies to calm themselves down. You’ll find these in the Turnaround Anxiety Program, but briefly they will be such things as breathing more slowly, relaxing your body, art, music, or busying oneself with playing or schoolwork.

One final tip I have is the use of the “Get Out Of Jail Free Cards.” Except not about jail. Let’s take the example of a child missing a lot of school because of emetophobia or always feeling unwell/stomach aches. Decide what’s an acceptable amount of school to miss for an anxious child. Let’s say it’s 4 days per month. So make up 3 cards that say “Get out of school free.” Give them to the child and let THEM decide (no negotiating by you) when to use the cards. If they need to miss school they give you a card and you allow them to stay home, no questions asked (NO questions asked!). I had one client that was afraid to take the school bus so she got 3 “Get a ride to school with mom” cards. Another young boy asked his parents and teacher several times PER HOUR to feel his forehead to see if he felt hot. He got 5 “feel my forehead” cards for the month. In each of these cases both their parents and I were amazed at how well this strategy worked. Before using a card, the child had to decide for themselves if it were worth it to “waste” a card that day. Maybe they didn’t feel so bad after all. Maybe they could make it all day. Maybe they could feel their own forehead. In short, the child learns to solve their own problems and comfort themselves.

As a final word, I want to point out something that may be obvious to most of you: when a child has problems, you must address them in priority order. First, is the child actually sick or in pain? They must be taken to a doctor and be checked out that there’s nothing physically wrong with them. Don’t diagnose anxiety right off the bat. Are they eating? Losing weight? This is a medical emergency. Are they sleeping properly and for long enough? If not, this needs to be addressed, even with medication. Lack of sleep is serious. Are they going to school every day? If not, you must address this with their teachers and perhaps look at alternatives for their education, at least until their anxiety is under control. Are you seeking professional help for them for their phobia/anxiety? You must – anxiety disorders are not something a child just “outgrows” – they need help in coping with it. Finally, are they socializing with other kids such as playing sports, music, dance, or just hanging out with them? This is important for children. Hopefully, you find good therapeutic help for them to lessen their anxiety so that they can participate in life again, and enjoy their childhood.

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/

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.

Emetophobia and the fear of sound

Emetophobia is not just the fear of vomiting. It is also the fear of anything to do with vomiting. The sight, the smell, the sound, the contagions. Most of my clients are more afraid of being sick themselves than they are of seeing or hearing other people. But yet, whenever someone in their own house is sick, they’re usually terrified that the family member has somehow contracted Norovirus and that they’re contagious.

I believe my phobia began sometime before I can really remember, but it was made a thousand times worse between the ages of eight and nine when my dad was sick with colon cancer. He was vomiting often, and it sounded like death. Sadly, he did die when I was nine so that probably reinforced the phobia for me. To this day no one has sounded as horrible or as unique as my dad when he was sick. I thought in later years that perhaps I was imagining it, or at least embellishing the memory. Until one day when I was in my forties I heard my aunt (dad’s sister) talking to another sister about how awful my dad sounded when he was sick. She recounted visiting him in the hospital once after he’d had surgery as a young man. In those days anesthetic was ether, and it made people terribly sick. The funny part about the story is that she went to the nurse’s station to ask his room number, but then heard him vomiting at the end of the hall in his room and knew right away by the sound that it was him.

As time went on, I married and had three children. My husband did not vomit for 32 years, even though he’s not the least bit afraid of it. I could not have chosen a more appropriate mate. But then there were the kids. When we had a young family we were pretty cash-poor, so there was no way I could go to a hotel room. After my successful emetophobia treatment we were a bit better off, but I no longer needed the hotel! Back when the kids were young if I heard anything that remotely resembled them being sick in the night I would race down to our basement rec room, curl up on a most uncomfortable couch and plug my ears tightly with my fingers. And cry. There was lots of crying back then. My kids would cry for me, and I would cry for myself and my husband was probably crying that he had to deal with it all. Those kids are 44, 37 and 35 now and I have seven grandchildren. They’re all very well-adjusted, educated and productive members of society with no phobias of their own and I have a great relationship with each of them. I share that not to brag, but to reassure you that if you’re doing what I did your kids can still turn out ok.

I’ve had clients who book a hotel room, who sleep in their cars, who go to their mother’s, who camp out downstairs or in the attic. One client insisted that their “mortgage helper” suite be left empty so she could move into it every time someone in the family was ill.

The treatment for emetophobia involves, among other things, desensitization to the sounds of vomiting. Most people with emetophobia are afraid of being sick themselves, while some are just triggered by the sight or sound. Either way, nobody likes to hear it. I used to have three or four sounds that I found on the internet which I went to great length to find, and used those in my emetophobia treatment program. But then I found this great website that has 88 sounds of vomiting, and it’s free for anyone to use! Here’s the link if you’re interested: https://www.soundsnap.com/tags/vomit You can begin by having your volume very very low, and then slowly increase it. Try all 88! The great thing is that it will desensitize you to the sound if you work on it, so you can be in a hospital ward with the curtain drawn, be a couple rows behind someone on a bus or plane, or be in your own house minding your own business and listen to someone vomit. It’s all the same. Good luck!