Information for Professionals, Sufferers and their Families
© 2004, 2011, 2019 Anna S. Christie, B.A., M.Div., RCC #6269
Permission is granted to sufferers of emetophobia to photocopy this article to give to their families, doctors or therapists.
Unauthorized reproduction or publication is strictly prohibited.
This article is written in a style intended to be accessible to phobics and other laypeople.
Emetophobia is more properly referred to as “Specific Phobia: Other Type: Vomiting.” The DSM-V diagnosis of emetophobia is 300.29 – Specific Phobia: Other Type. “Other Type” refers to “situations that might lead to illness, choking, vomiting.” Despite the fact that most people, including many doctors, health workers and therapists have never heard of it, emetophobia is quite prevalent, affecting approximately 7% of the population (Philips, 1985). In the United States alone, that would be 23 MILLION people. Since there is much shame and embarrassment over this phobia, the average person knows little if anything about it. Emetophobics hide their debilitating panic well.
Since the phobic fears her own body, this disorder tends to be particularly difficult. Avoidance of the stimulus is impossible, and thus without treatment the emetophobic is continually re-traumatized, ritualistic behaviour intensifies and the condition worsens. Most emetophobics have both avoidance and safety behaviours.
Most sufferers of emetophobia fear vomiting themselves, while a smaller percentage only fear seeing/hearing someone else vomit. The diagnosis and treatment are the same.
Emetophobics are terrified of vomiting – most of them anywhere, anytime. Others only fear vomiting in front of someone else, or seeing someone vomit. Symptoms range from mild disturbance to acute panic attacks (rapid heartbeat, rush of adrenalin, difficulty breathing, choking sensations, derealization, dizziness, fear of dying, numbness, sweating, trembling). The derealization can be akin to a PTSD-flashback with the client completely dissociating.
Most emetophobics report quite sincerely that they would rather die than vomit. For many, vomiting and death anxiety are inextricably linked. In severe cases, emetophobics will show symptoms of OCD and agoraphobia. (They will wash their hands until raw for fear of germs from an illness that will make them vomit – they may fear seeing someone vomit or catching germs so much that they will not leave the house.) Many emetophobics have other symptoms of OCD, such as a variety of rituals to keep from vomiting or to reassure oneself that one is not sick (i.e., obsessive temperature-taking), or superstitions about numbers and dates (especially the date they last vomited). The following are characteristics of most emetophobics:
- excessive cleanliness
- fear of eating outside of one’s home, or eating food one has not prepared (in case it may lead to food poisoning which would cause vomiting)
- nausea, stomach cramps, diarrhea a great deal of the time. (While these symptoms should be checked out, they are usually due to anxiety.)
- fear of taking any prescription medication that may have nausea or vomiting as a listed side-effect.
- fear of animals who vomit
- fear of all children (as they vomit more often, sometimes without warning, and they are more prone to viruses)
- fear of pregnancy (due to morning sickness, or vomiting at delivery)
- fear of anesthesia – due to vomiting as a side-effect
- fear of hospitals and nursing homes
- fear of traveling (in case they are motion sick, or someone else is)
- fear of alcohol consumption, or parties where alcohol is consumed
- fear of amusement parks where people may be sick on rides
- fear of television and movies (more and more, vomiting is becoming commonplace in the media)
- fear of psychotherapy (lest it involves exposure therapy they feel they can’t handle)
- fear of a number of jobs, limiting career choices. (Emetophobics also often have difficulty holding down a job, due to the number of sick days they take.)
- fear of sick or injured people no matter what they have, as vomiting can be a symptom of every illness.
- fear of public toilets (as someone may come in there and vomit)
- fear of others’ coughing, burping, touching their stomachs, looking pale, saying they don’t feel well
- nightmares – particularly about vomiting, but night terrors are common as well
- refusal or inability to actually vomit. Most emetophobics do not vomit at all but for exceptional circumstances.
- anger, frustration and despair at not being understood, believed or supported – especially about the severity of the feelings of terror and horror.
When emetophobics encounter someone who is vomiting, or feels ill, they will:
- panic immediately, often with incredible immediacy (The panic attack will not necessarily rise up slowly – so inserting cognitive “tools” is not always a possibility. Again, this depends on the severity of the disorder.)
- become dissociative and completely irrational, often crying, screaming, and sometimes harming themselves or others.
- feel nauseous themselves and be convinced they will also vomit
- run away at high speeds, despite risk to personal safety or the well-being of their children
- refuse to remain in the house, car or enclosed place with the sick person even if it is their own child or a family member who “needs their help”
- if trapped, close their eyes and plug their ears (sometimes for an entire night)
If emetophobics feel nauseous, or believe for some other reason they may vomit they will often:
- refuse to eat or drink (they think they can’t vomit if their stomach is empty)
- assume all gastro-intestinal feelings are nausea, which will lead to vomiting. (This may also extend to mistaken feelings about dizziness, headache, body temperature, etc.)
- refuse medical help (in case they are trapped in a hospital with more sick people)
- refuse medication (in case the side effects are nausea/vomiting)
- panic, and continue to have a series of panic attacks over long periods of time (as they are unable to avoid the stimulus which is their own body)
- assume (incorrectly) that a symptom of the panic attack itself will be vomiting3
- pace, cry, beg others to help, run from others, scream, become dissociative, self-mutilate (scratching skin, hair-pulling, cutting), bring harm to others.
- insist on being alone, or insist on having a significant other with them.
- refuse to go near a toilet or other receptacle, or refuse to be anywhere else for unusually long periods of time.
- try a number of over-the-counter medications to control vomiting (Pepto Bismal, Dramamine, Peppermint, Ginger). Some emetophobics ingest large amounts of these remedies over time.
Most professionals agree that no one thing causes anything. Some emetophobics report a traumatic experience with vomiting, almost always in childhood, but many do not. Many psychotherapists assume that sufferers are victims of childhood abuse – sexual or physical. While this is occasionally true, it seems to be no more prevalent than in the general population. (In my own case, I was a survivor of several childhood traumas involving sickness: my mother went into hospital for several months when I was an infant, my brother died tragically in hospital when I was 4, and my father died of cancer – vomiting intensely – when I was 9. Despite all this, every one of 10 non-helpful psychotherapists I saw for the disorder tried to look for another cause, suspected sexual abuse, or could not believe that this history would produce such dramatic symptoms. I eventually found a therapist who could help me.) Again, it is to be stressed that the details of sufferers’ lives are many and varied. Anxious families, trauma, separation anxiety and/or anxious focusing on the child are common to all sufferers, however these conditions do not always cause anxiety disorders, nor do they always cause this one, so of course there are probably hereditary factors as well. Whatever the root cause, vomiting now presents an unrealistic and horrifying sense of danger to the client. For this reason, safety is a primary issue.
A strong therapeutic alliance is imperative. If you cannot (or your technique demands that you do not) emanate a genuine sense of warmth and compassion, you are not the right therapist for this client. She is as terrified of vomit as you are of an impending, horrible death. Cognitive-behavioral methods (especially very gradual Exposure and Response Prevention) should be applied gently and only in the context of a caring, trusting relationship. When in doubt, revert to client-centered techniques, validation and support.
Be sure before you agree to treat this client that you are comfortable enough yourself with vomiting. Treatment may entail a lot of talking about vomit, listening to sounds of vomit, viewing pictures or videos of vomit and perhaps accompanying the client to an in vivo situation involving vomit. If you can’t handle this, you need to be honest at the beginning and refer the client elsewhere.
Many emetophobics have been misdiagnosed as presenting with any or all of the following:
- anorexia nervosa (Many emetophobics are anorexic, but usually only because they fear they will vomit. They often have no other symptoms of this eating disorder.)
- obsessive-compulsive disorder (Many emetophobics do, in fact, present with symptoms of OCD, but some simply wash their hands excessively for fear of germs that will lead to an illness causing vomiting. A misdiagnosis of OCD is not that important, as treatment is virtually the same, however many emetophobics are distressed at the thought of having more than one mental illness. One of the important things to consider before making a diagnosis is to ensure “if the patient has another Axis I disorder, the content of obsessions or compulsions is not restricted to it.”
- social phobia (Many emetophobics diagnosed with social phobia have no other symptoms of the disorder except that they fear vomiting in public. It may be that they simply have a strong component of shame associated with their phobia.)
- agoraphobia In severe cases, emetophobia limits the sufferer from leaving the house at all for fear of catching a virus or seeing someone vomit.
- repressed memory (While this may or may not be a bona fide condition, it is not necessarily indicated in cases of emetophobia. Most emetophobics cannot think of one single incident that “caused” their phobia – it seems to develop over time in childhood for a variety of reasons.)
- irritable bowel syndrome (IBS) (Some emetophobics could well have this medical disorder along with their phobia; however the current literature suggests that IBS may be an anxiety-related illness in the first place. Typical remedies or medication for IBS seem to have little positive result for emetophobics.)
- schizophrenia, bipolar disorder, other psychoses, depression. The client should be very carefully screened for severe mental illness with the complete understanding of the symptoms of emetophobia in mind. While some emetophobics are indeed severely mentally ill, most are not and have been diagnosed as such and treated inappropriately.
- PTSD. Symptoms of emetophobia can often be so impressive that the correct diagnosis is PTSD – especially if an incident or incidents of trauma are specifically remembered. Some emetophobics describe nightly nightmares, dissociative incidents, extreme feelings of terror and horror, and debilitating panic attacks. The “flashbacks” with emetophobia are sometimes somatic flashbacks only, depending on whether the disorder is tied to one single incident or time in one’s life.
The standard treatment for emetophobia, as any anxiety disorder, is Cognitive-Behavioral Therapy (“CBT”) involving gradual exposure and response prevention (ERP). The problem with this unusual disorder is that it can be quite difficult to build a hierarchy of fears for exposure that the client feels comfortable with. All-too-often the therapist errs by beginning with a fear too far up the hierarchy, or jumping “steps” and scaring the client off. It cannot be emphasized enough how afraid these clients are. They are afraid to take medication, afraid to try exposure, and afraid to talk to you! A gentle, caring manner is therefore imperative no matter what the treatment.
I have set up an online emetophobia resource page on this website (click on “resources” in the menu bar). It’s set up in a hierarchy of fears that is appropriate for most emetophobes. You are free to use it in any way that is helpful to you and your client.
Since your client has undoubtedly presented you with this paper, he is probably already as informed as you are about treatment by now. Be sure to discuss your treatment approach honestly and openly with the client. Try to discern what he thinks about exposure therapy, and how frightened he is of it. Remind him that he does not have to try to deal with what’s at the top of the hierarchy – only with the first step. Reassure him that you will not force him to move farther up the hierarchy until he is completely ready.
If you are trained in EMDR, many have found this to be an excellent technique to “get at” the underlying emotions and root causes. I personally enjoyed great success with EMDR, even though it was not any sort of “instant” or “miracle cure”. It was, however, an important part of an overall treatment program. Some emetophobics have reported similar experiences with hypnosis. (However, many report disappointment that hypnosis or EMDR alone did not lead to a “cure”, as promised.)
In extreme cases or where there are other presenting disorders (agoraphobia, OCD, depression) anti-anxiety medication may be indicated. Many emetophobics will respond well to it, however I would like to point out that a number of them who correspond with me on the internet report their tremendous fear of taking the medication and their reluctance to tell their psychiatrist (out of shame or fear of her anger). One sufferer told me her psychiatrist continually upped the dosage and then wondered why it wasn’t working. The truth was the patient wasn’t taking it. If you need to prescribe such medication, you may wish also to prescribe a powerful anti-emetic for the first couple of weeks, and reassure the patient that it will work, and he will absolutely not vomit. Be as gentle, caring and open as you can, letting the patient know that if he is too afraid to take the medication, you will not be angry or abandon him. You will simply try something else. In extreme cases, anti-anxiety meds can be compounded into a cream absorbed through the skin. You may consider this possibility for a patient unwilling to take the medication orally.
Emetophobia cannot be successfully treated in 8-10 standard sessions. In my own case, even as a trained counselor myself, it took me over 10 years to figure out that promises of a “quick fix” left me feeling disappointed, guilty or insulted – and certainly not treated. Once I was able to afford long-term therapy, and to commit to it, I participated in over 25 hours of therapy before I was even able to tell my therapist the exact nature of my fears (most of the things written on this page). It took me close to 35 hours to trust him enough to agree to begin any sort of treatment. 60-70 hours later, I consider myself anxiety-free.
I do not mean to imply that a shorter treatment time, especially in milder cases, will not bring significant symptom relief. Genuine care, cognitive work, gradual exposure, response prevention. This is the tried-and-true formula that seems to bring the best results. Motivated clients who can commit to and afford longer treatment will have a greater chance of experiencing overall emotional growth and will be less likely to see recurrence of symptoms under stress. I now treat most emetophobics in about 16-20 sessions.
Whatever you do, do not suggest to the client that he should vomit in order to get over the phobia. This is akin to telling a war veteran with PTSD they have to go back to the war to be cured or those who fear cancer need to get cancer. Many sufferers and psychotherapists alike have tried various forms of this “flooding” – none of them have reported success, more than a temporary relief of symptoms or fleeting reassurance. Almost always it results in re-traumatization.
It is always unhelpful to start at the very top of the hierarchy of fears. Often even the therapist suggesting that vomiting might be a good idea someday down the road will result in the client running like mad. I have talked to hundreds of emetophobics over the years and not one of them has ever experienced a reduction in anxiety levels after an episode of vomiting – whether by chance, or intentionally induced. Therapists skeptical of this would be advised to do some research on Psychogenic Faecal Retention, the fear of defecating. These phobics obviously have to defecate, although they often avoid it as long as possible. However, the act of defecation does not treat them, much less cure them. (Click here for further info)
The goal of therapy is not for the client to vomit – it is for the client to be free from anxiety. In my own case, once my anxiety was reduced, my flawed thinking was restructured, and I could recognize body feelings as normal I no longer spent time thinking about vomiting and began to enjoy life. When I did vomit (some 10 years later) I was anxious for a few minutes only, then realized after it was over that I was in no danger.
In most cases, reassuring the client that her vomiting is not necessary for the treatment will go a long way in establishing trust. The same is true for family members and friends.
Fear of Seeing Others Vomit Only
This form of the phobia is extremely rare and little is written about it. Nevertheless, it exists (I eventually suffered from it myself) and in many ways it is easier to treat as the gradual desensitization methods work smashingly well. After working through all of the resources on this website you may wish to schedule some in vivo (“real life”) exposure in a hospital, if possible.
Further Information and Resources
For further information or discussion, professionals or emetophobes may feel free to contact me. If you are viewing this article in print form, you may also wish to visit my information website at http://www.emetophobiahelp.org.
About the Author
I am a registered clinical counsellor with a history of severe emetophobia. My own treatment involved group therapy in 1983 as part of Dr. H.C. Phillips’ research study. Dr. Phillips wrote one of the first scholarly journal articles on emetophobia (see below). This treatment brought me temporary symptom relief but symptoms returned over the years until in 2001 when I designed my own gradual exposure hierarchy and worked through it with a person-centered therapist with CBT. At one time my symptoms were so severe I was diagnosed with PTSD. Yet I now enjoy a life completely free from any diagnosable symptoms of anxiety. Thanks to the accessibility of sounds, pictures and videos of vomiting on the internet I have now designed a program of treatment for emetophobia sufferers that takes far less time than my own treatment. I also share these resources freely with anyone who can use them on my internet emetophobia resource page. I am also happy to correspond by email, free of charge, with any therapist interested in treating emetophobia or schedule a professional consult on Skype (fees apply).
Campion, J. 2003. I was so scared of being sick, I starved myself. Zest. July/03: 42-43.
Klonoff EA, Knell SM, Janata JW. 1984. Fear of nausea and vomiting: the interaction among psychosocial stressors, development transitions and adventitious reinforcement. J Clin Child Psychol 13: 263-267
Lipsitz, JD, Fyer, AJ, Paterniti, A, Klein, D. 2001. Emetophobia: Preliminary Results of an Internet Survey. Depression and Anxiety 14: 149-152.
Phillips HC. 1985. Return of fear in the treatment of a fear of vomiting. Behav Res Ther 23: 45-52.
Veale, David and Lambrou, Christina. 2006. The Psychopathology of Vomit Phobia. Behavioural and Cognitive Psychotherapy 34: 139-150.
Veale, David. 2009. Cognitive behaviour therapy for a specific phobia of vomiting. The Cognitive Behaviour Therapist 2, 272-288.