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!

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.

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!

Being Thankful

As an emetophobic, it can be hard to truly appreciate the holidays. You often have to travel by car or plane, stay at someone else’s house, eat food cooked by someone else, and put up with all the family members including little ones who can be germy to say the least.

Our Canadian Thanksgiving has passed now, but I am aware that most of my clients are from the USA, and their Thanksgiving is looming. Not being thankful, in fact not enjoying oneself, can bring with it guilt and shame. Everyone else is having a good time sharing food and wine, stories and games. You might be curled up in a chair away from people staring at your phone, not wanting to eat. “Waiting.”

Many ask me if I have any “tips” for getting through the holidays. I do not. Recovering from a serious anxiety disorder such as emetophobia is not about tips or five steps to a cure, or a quick fix. It is a slow, methodical process; a road that is straight uphill. Let me share this with you, however: you can do it. You can get through the holidays; you can cope with whatever happens. You know darn well you’re going to wash your hands and not put them or anything you’ve touched in your mouth anyway. So the chances of YOU getting sick are pretty much non-existent. If other people are sick that would be upsetting, but nothing bad will happen to you. You may be afraid, but you’ll be ok. Try to remember this – write it on a little card, perhaps, and take it with you for the weekend. Refer to it whenever you feel your anxiety start to rise.

What about being thankful? Everyone else will talk about being thankful for food (probably not you) and for family (even those germy kids?) and for other various aspects of privilege. You may feel that while you’re suffering so much, you don’t feel very thankful for your life at all. When I was a kid, I made the same wish blowing out the candles on every birthday cake: I wish I didn’t have this phobia! I figured the wishing didn’t work. But here I am at 61, nearly twenty years completely free of it. So maybe it worked after all. It just wasn’t instant.

Here are a few thanksgivings to ponder:

  1. I am thankful that I live in America (or any other country that celebrates Thanksgiving). There is treatment for emetophobia here.
  2. I am thankful that I live in the information age, so I can find out lots about emetophobia right at my fingertips.
  3. I am thankful that I live in the age of Social Media, so I don’t feel alone with this and it’s pretty easy to have someone to “talk to.”
  4. I am thankful that people are studying emetophobia and conducting research all the time, so it may be easier to get treatment very soon.
  5. I am thankful that people are working diligently on developing a Norovirus vaccine!

What Causes Emetophobia?

This post has been moved from my previous website.

Like any other phobia or anxiety disorder, the exact cause is unknown. Why do some people develop a phobia of dogs after being bitten by a dog as a child, but others do not? Some folks remember a traumatic incident involving vomiting when they were young. Perhaps they were vomited on, or they vomited in school and were embarassed. Yet this happens to many children and not all develop phobias. So although scholars do not know the exact cause, there are many things they do know.

  1. Phobics have a genetic predisposition to anxiety. Probably your mother, father, or one of your grandparents was an anxious person. It may be an aunt or uncle. Whoever it is, it’s in your family. That person may have been able to hide it, but it will be there. Genetics (nature) only accounts for about half of the cause, however. The other half is experience (nurture).
  2. Most emetophobics that I have spoken with online (thousands) or worked with as my own clients (over one hundred) had something happen to them in childhood that disrupted the normal resolving of attachment with their mothers. When I say “resolving” I mean that as babies we have a very close attachment to our moms, however with the passage of time this naturally resolves and we begin to trust the world, other people, and can manage on our own (“independence”/”interdependence”). The disruption of the attachment resolve does not need to be dramatic, however it certainly can be: death, abuse, neglect, abandonment (trauma). It can be something quite minor: mom returns to work, mom is in hospital having another baby, mom is concerned with her ailing parent. It can also be a trauma or attachment event that happens before you were old enough to remember. Adoption is a one example. 
  3. Regardless of your genetics or your childhood experience, there are three major factors that turn these into a phobia, and keep the phobia going: 

I believe that one of the reasons that the fear of vomiting presents as so severe in most cases is that we naturally “avoid” vomiting throughout our lives. It just doesn’t happen that often. Young children vomit more often as their gut has not yet fully developed. But by about 13 your gut is an “adult” and you may only vomit once every 10 or 20 years. This kind of avoidance cannot be helped, so the factors of safety behaviours and anxious thoughts are  much more prevalent in keeping emetophobia going or getting worse. There are two types of safety behaviours, and there is disagreement among scholars as to whether both are problematic for emetophobia or just the first one:

  1. SAFETY BEHAVIOURS TO AVOID VOMITING
  2. SAFETY BEHAVIOURS TO AVOID PANIC (CALMING DOWN)

Let me begin by saying that I only believe that safety behaviours which avoid vomiting (germs, norovirus) are problematic, and behaviours to avoid panic and calm down such as slow breathing, muscle relaxation, etc. are a big part of the way out. 

Some common examples of emetophobia safety behaviours are:

  1. ​OTC medications (Dramamine/Gravol, Pepto Bismal, Tums)
  2. Prescription medications (Zofran/Ondansetron, Ativan, Xanax)
  3. Ginger, gingerale, ginger tea
  4. Mints, gum
  5. Sipping water
  6. Excessive cleaning (bleach)
  7. Excessive hand-washing or using hand sanitizer
  8. Not touching doorknobs, light switches, gas pumps
  9. Not touching your face
  10. Running away/avoiding sick people

There can be any number of others. The problem is that as soon as you employ a safety behaviour and don’t vomit, your brain will assume that the safety behaviour “saved you” and the situation was actually a dangerous one that you avoided this time. In reality, the situation wasn’t dangerous at all, because vomiting isn’t dangerous. Nobody likes it, but it’s actually helpful to you as opposed to a danger to you.

SLOW, DEEP BREATHING, relaxing large muscle groups, meditation, or imagining yourself going through a situation like a “normal” person are behaviours used to calm oneself and I do not consider them safety behaviours. Some schools of thought disagree with me, but I’m not alone in this idea. Learning to truly relax in the face of what I once considered was danger, was the way I got over my phobia.