What is CBT? Does it help Emetophobia?

“CBT” stands for “Cognitive-Behavioural Therapy.” This therapy is quite well-known because it’s known as “evidence-based” meaning there is good evidence that it works. It is well-researched as a treatment for both depression and anxiety, including anxiety disorders, phobias and Obsessive-Compulsive Disorder (“OCD”).

Evidence of the effectiveness of CBT is discovered by way of a proper research study. Typically, researchers find a group of people with the same disorder – let’s say spider phobia. They test the whole group to get a numerical score as to how severe their phobia is. They then divide the group randomly into two and treat half the group with CBT while the other half sits on a waitlist. After the first group has been treated, both groups will be tested again. Study after study has found that the CBT group gets significantly better, while the waitlist group generally does not. The researchers will then treat the waitlist group out of courtesy to them for being involved in the study. To date over 1,000 research studies have been done on CBT.

CBT is made up of two originally separate theories and types of therapy. You guessed it – cognitive, and behavioural. Cognitive therapy was first theorized by Dr. Aaron Beck who at this writing is still alive at the age of 99 years. He was lecturing until about five years ago. Dr. Beck is also known as the father of CBT.

Dr. Aaron Beck

The basis of cognitive theory is that a person’s thoughts about a situation or topic relate more to their anxious or depressed reaction than the situation or topic itself. In other words, you are afraid of something because of your thoughts about it, not because it is inherently dangerous. Most emetophobic people I work with believe, for example, that vomiting is a huge, horrible, catastrophic event akin to a bloody murder scene. In reality (the reality of everyone who does not have emetophobia), vomiting is a normal, natural event that happens rarely which nobody likes but everyone feels better afterward.

Simply pointing out reality to a phobic person does not help them, as each of you reading this knows all too well. The logical, rational part of our brains knows the truth, but the part of our brains that is responsible for our survival does not know. For some reason, and the reasons are varied, vomiting or the thought of it triggers this survival instinct and we feel like we are dying even though we know full-well we are not.

Enter Behavioural therapy. Behaviour is often a word associated with children, but in this context,  it sort of means actions  or what you do. Early behaviourists include Ivan Pavlov (remember his dogs?) and Dr. B.F. Skinner. Behaviourism says that you will keep doing things that reward you or make you feel good, and you will not do things that punish you or make you feel bad/uncomfortable. With emetophobia you may avoid yogurt past its expiry date because if you eat it you will feel anxious. When you’re nauseous, one behaviour might be to suck on mints because they make you feel better and therefore less anxious. Avoiding what’s bad and doing what feels good may be fine for a neurotypical person, but for a phobic whose brain wiring is a bit criss-crossed it has the opposite effect. Every time you avoid the yogurt you feel better, so it reinforces that you should always do that. When you suck mints and then don’t vomit, you feel better, more relieved and calmer. This reinforces that you should do this every time you feel sick. Unfortunately, these avoidance and safety behaviours make your phobia get reinforced and it continues to get much much worse.

From Getselfhelp.co.uk

CBT for emetophobia means that your therapist will help you to slowly turn your behaviours around to the other direction. They will begin with something easy, such as looking at the word “vomit” on a page, then just allowing your anxiety to raise slightly and then lower to the baseline level, training your brain that this non-avoidance can also make you feel good, relieved and calm. Then you’ll slowly go up the ladder to look at things and do things you wouldn’t normally do. The whole time, your therapist will be with you and watching you to ensure you don’t get overwhelmed. They will also be helping you examine your thoughts along the way to ensure that you will, by the end of treatment, be able to say with confidence “Vomiting isn’t dangerous or harmful. It’s ok if it happens because I can cope with it.”

Lori Riddle-Walker, a colleague of mine who sadly died of cancer after completing her research study, was the first person[1] to study the efficacy of CBT on emetophobic patients. The preliminary findings were that it did indeed help people with a fear of vomiting get significantly better.


[1] The study was done in conjunction with Dr. David Veale who is the world’s leading researcher on emetophobia in the English-speaking world.

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!

B.R.I.T. – A Way to calm anxiety

According to the experts – scientists who study anxiety and treatments – the best way to deal with an anxiety or panic attack is to do nothing. Just let it be. Don’t run away from what triggered it, don’t use a safety behaviour so you’re not sick, don’t even think about it, which means don’t battle it in your mind and try to stop it. If you can do that, then the anxiety will come to a peak and then slowly dissipate on its own, all within 15-20 minutes. EASY FOR THEM TO SAY, EH?

There – you got my little bit of Canadian for today! The formula, according to said experts is:

Notice it

Acknowledge it

Don’t engage with it

“Just notice it” my therapist used to say. It made me so mad. How the H-E-double-hockey-sticks could I NOT notice it? (I’m on a Canadian roll now, eh? Go Canucks!) But seriously, I used to go from 0-10 in 1/5000th of a second. I wondered if anyone who came up with these ideas had ever actually had a panic attack. It troubled me deeply as I sought to help others with their emetophobia because I assumed that everyone was like I used to be.

As the years and the clients clicked by I started to notice a pattern with them. They were not like me. In fact, I have met or talked online to very few people who reacted as I did to the triggers. I basically felt well and healthy every day of my life. I never felt nauseous, icky or “off.” So I’d be going along minding my own business when one of my three kids would come up to me and say, “Mom, my tummy hurts.” ZAPPO! 10/10. I had no time to “notice it” or “acknowledge it” – that was just crazy talk. Ironically, once I was successfully treated for the phobia and wasn’t afraid of vomiting anymore, I started to notice that I got anxious about other things. It’s like before – if everyone was feeling good – I didn’t care what else happened to me or anyone else in the world. No one was going to vomit, so everything was great! Once I got over the emetophobia I realized that I was still an anxious person, because I was born that way (and so were you). NOW, when the grandkids go to the playground I’m the one thinking OMG HE’S ONLY 2 AND HE’S AT THE TOP OF THE SLIDE!!!! My point? It’s not 10/10 – it’s maybe 4 or 5, and then the more I watch him the more it creeps up and up and up. I just let it be, and eventually it goes away on its own.

Many of my clients are like that with emetophobia. They wake up feeling “off,” so they’re a little nervous – maybe 3/10. Then they eat breakfast and start to feel icky – 4-5/10. Then as the day wears on icky turns to worried which makes the icky worse and the numbers creep up. Now, I understand that your experience may also be different than that, but the point is that if your anxiety moves up slowly, then the experts are correct: do absolutely nothing about it.

Today’s little acronym is “B.R.I.T.” (How do you like that, peeps in the UK? eh? eh?) BRIT is not for the slow climb – just notice, acknowledge, and don’t engage those. BRIT is for the times when it goes HIGH QUICKLY. Or when you just can’t “do nothing” about your anxiety, and so it continues to rise. BRIT are the ACTIONS (Remember last week’s “A” in the STAR plan?) needed to calm down. They’re all tools you carry with you every single day. You don’t need a safety kit in your purse. You just need BRIT. So let’s go through them one by one.

Breathe

Your breath is your salvation! Learn to breathe slowly and evenly, deep into your abdomen. Let the out-breath be longer than the in-breath. Try “7-11 breaths” – breathe in for 7 counts, out for 11. Check out my YouTube Video on how to breathe properly to help bring anxiety down: https://youtu.be/PPkUWoloQog

Relax

“Relax” means to relax, soften and drop the large muscle groups in your body starting from your forehead and eyes, and extending down to your toes. In order to do this effectively you have to practice it. I give all my clients a sheet of paper with the numbers 1-90 on it so they can check off the number of times they listened to a 20-minute recording teaching progressive muscle relaxation. Just putting on a recording when you’re anxious will not help you very much. You need to learn the technique much like learning a piano concerto or an entire hip hop routine. You can’t just tell someone to do either of these – they have to learn the notes/steps and practice until it’s just “body memory.” It’s the same thing with this. Your body has to know where to go. Here’s a link to one of my progressive muscle relaxation recordings. There are many more on YouTube: https://youtu.be/XfF5Srxtj9M

Shout out to PianistMiri who improvised on harp with me to make these! https://www.youtube.com/user/pianistmiri She does WICKED piano covers of popular songs!

Imagine

Studies have been done on the brain where a person was shown an object such as a cabbage in an fMRI machine. The next day the person was put in the MRI machine again and told to remember the object from the day before. The cool thing is that the brain lit up exactly the same way. Like, exactly. So of course the “logic” part of the brain knew the cabbage wasn’t there – that the subject was just imagining it on the second day. But the rest of the brain did not know. Psychologists got hold of this and used it for anxiety recovery. Imagine you are in the most peaceful, tranquil, calm and beautiful place in the universe. Really imagine it. Your brain won’t know you aren’t actually there.

Using the “imagine” tool may be helpful when sitting on in an airplane, but not as helpful if you’re at the front of the room giving a presentation. It’s ok – you have three other tools.

Think

Sometimes when we’re busy emoting (aka freaking out) we fail to THINK. Thinking can calm the troubled mind and body. Use positive, calm and rational thoughts. I used to write mine down on a business card and carry it with me all the time when I was working on my emetophobia. I volunteered at the hospital, and one day I walked into a patient’s room and she was very nauseous, holding one of those cardboard bowl things under her chin. I could not take the card out and read it, but I reached into my pocket with my hand and just felt it. That really helped. Here are some positive thoughts (“positive cognitions”) that have helped me, and many of my clients. In fact, my clients came up with most of them:

  • You’re not in any danger
  • It feels dangerous but it isn’t
  • Usually the worst doesn’t happen
  • If it really happens, your anxiety will go down.
  • Vomiting isn’t dangerous or harmful. It can’t hurt me, so I don’t need to be afraid of it
  • There’s no point being afraid all of the time for something that happens so little of the time/rarely
  • It doesn’t matter if I vomit
  • Even if I get sick, I will be ok.
  • I’m perfectly safe
  • It doesn’t matter
  • I can cope with vomiting

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!