What is emetophobia?
When does a concern with vomiting become a phobia?
How do people with emetophobia cope?
You may also have a number of "safety seeking behaviours". These are things you do that you believe will prevent yourself or others from being sick. These include excessive checking of sell by dates and freshness of food; seeking reassurance; excessive cooking of food; excessive washing of hands or cleaning of the kitchen area with anti-bacterial sprays and gels; superstitious behaviours such as "not stepping on a 13th stair" repeating a word or action a certain number to prevent yourself from vomiting. People with emetophobia frequently drink bottled water or a sugar fizzy drink. These behaviours may also be a way of checking whether you are going to be sick (e.g. "If water's going down, then nothing can come up"). You may take anti-nausea medication or suck antacids ice or mints.
You might also be telling yourself certain things in your head - for example reassuring yourself that you or someone else will not be sick. Even though it is probably impossible people may attempt to mentally to control the reflex act of vomiting. This makes you feel more in control but increases your preoccupation and distress.
All these avoidance, safety seeking behaviors and
being extra-vigilant keep the problem going. They make you think that
they work (in the sense that you do not vomit) but have the unintended
consequence of increasing your awareness of feeling sick and the preoccupation
with vomiting and making you more anxious. This becomes a vicious circle.
In short, it is your solutions that have become the problem and are now
maintaining the fear.
Developing a specific phobia of vomiting is highly understandable given the way that humans (and animals) can become easily conditioned after food-poisoning or an infection and are more likely to avoid situations that remind them of vomiting. Vomiting as a baby or as a child could be very panic inducing (for example the association with the feeling of suffocating, choking or death). Even if as an adult you know these associations are not true now, they are still powerfully linked in your mind. However, these associations can also be unlearnt and the "ghosts of the past" can change.
How common is emetophobia?
Is emetophobia linked with other illnesses?
Why do humans and animals have to vomit?!
People with emetophobia may believe that if vomiting did occur then it will last for many days. In fact, after an infection or food poisoning, it usually lasts at the most a day or two.
Others believe that they can influence or control their vomiting in an almost magical way. However, the act of vomiting is a primitive reflex act that cannot be inhibited. People with emetophobia tend to focus on the risk of infection or food poisoning but the reflex can be triggered by a wide variety of triggers around the body (e.g. mechanically in gynaecological problems; a extremely stretched gall-bladder or stomach; by certain drugs; metabolic problems that act on the brain stem; extreme fear; severe pain; certain smells can all induce vomiting in the right context).
There are treatments available that are described each in turn. There has been very little research to know the best treatment for emetophobia. This is why our centre is conducting research so we can slowly understand more about the cause and treatment. Current treatments described include cognitive behaviour therapy, hypnotherapy and medication.
What is Cognitive Behaviour Therapy?
Cognitive behaviour therapy (CBT) consists of a structured programme of self-help, helping you to get a good understanding of how the fear might have developed and how your solutions have now become your problem and keeps the fear going. It is based on an understanding that people with emetophobia have had one or more bad experiences of vomiting from childhood. Sometimes these experiences can be remembered, sometimes not. These memories have become associated with fear. Past experiences of vomiting (and their triggers) become fused with the present so that they are re-experienced as if they are about to be repeated. Once the link with the past experience is learnt, the anticipation of vomiting leads to anxiety. Anxiety causes nausea and other stomach symptoms. This becomes linked to the idea of vomiting and losing control. This is associated with extreme fear and past experiences of vomiting in a vicious circle.
There are then various ways that people with emetophobia
cope with the idea of vomiting. These are not bizarre - it is a very natural
response to fear.
All these ways of coping make you feel that you have more control in your ability to stop yourself from vomiting or that you are doing something to reduce uncertainty. However they will have the unintended consequence of increasing the frequency of thoughts about vomiting and symptoms of nausea and make you more anxious in a vicious circle. The solution therefore involves some combination of (a) updating early memories of vomiting by using a technique called imagery rescripting and (b) gradually dropping your avoidance and safety seeking behaviours. You will not be asked to induce vomiting - this is not necessary. There are no risks or side effects of CBT other than the experience of anxiety and old memories.
Having emetophobia can make like very restricted and
part of therapy will focus on helping you to do what is important in your
life despite your fears. Over time the degree of distress and preoccupation
with vomiting should decrease. We are not saying it is easy but it is
definitely possible to make your life more manageable. There are no published
rates of success using CBT, but we hope to do this in the future.
There is no evidence in the literature apart from one case study for the benefit of hypnotherapy in emetophobia. Please beware of unscrupulous commercial practitioners and if you chose this route, check that the practitioners belong to a recognised body such as the United Kingdom Council of Psychotherapy.
What about medication?
There is no evidence from any controlled trials that medication is of any benefit in emetophobia. There is a rationale for a type of medication called a selective serotonergic reuptake inhibitor (SSRI) in those with severe symptoms that overlap with Obsessive Compulsive Disorder (OCD) and who are unresponsive to cognitive behaviour therapy (CBT). Nausea is a potential side-effect of a SSRI which may mean that it is an unacceptable approach for some.
How can I get help for emetophobia?
If you're worried about talking to your GP, consider
writing down your concerns and questions. You can:
Some areas now allow you direct access to a new psychological treatment centre (without going through your GP). These are part of the new NHS Improving Access to Psychological Therapies centres.
NHS Direct can offer you advice on moving to a new GP practice. You can phone them on 0845 4647. Alternatively try to discuss your treatment choices with family, friends, doctors or other health professionals.
Dr David Veale, FRCPsych (www.veale.co.uk)