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Emetophobia (Fear of Vomiting): Information for Health Care Providers

Summary: On one hand, it is normal to dislike the thought of vomiting. On the other hand, for some people, the fear of vomiting (emetophobia) is so overwhelming that it ends up controlling their life. In order to avoid situations where there is the slightest possibility of vomiting, people can avoid going out, ending up housebound. As a result, they may end up unable to attend school, work, or participate in their community. The good news is that many services and supports can be helpful for overcoming emetophobia.
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What is Emetophobia?

It is normal to dislike the thought of vomiting.

Having just a little fear of vomiting is actually helpful. It encourages one to 1) stay away from people who may be sick, and 2) take measures to avoid getting sick. However, it's a problem when that fear starts to get in the way of one's life.

However, for individuals with emetophobia, the thought of vomiting is so terrifying that it can end up controlling a person's life.

Epidemiology

Mean age of onset: Age 9 (Lipsitz et al., 2001).

Prevalence of 2% in men, and 7% in women (Van Hout, 2006).

Etiology

It is believed that for most people, there is an event that triggers a fear of vomiting. It may have been a real-life event such as getting sick and feeling nauseous (e.g. having the flu or food poisoning), or it could have been even seemingly harmless events like watching something on TV.

In many cases however, individuals can’t actually remember that event.

Clinical Presentation

The person may:

  • Avoid going out, due to fear of vomiting
  • Avoid eating in public places (such as restaurants), or with other people
  • Avoid any place or situation where there is the slightest possibility that the person (or others) may vomit
  • Become upset even at the mere mention of the word ‘vomit,' or synonyms like ‘throw up', ‘barf,' ‘puke,' etc.
  • In some cases, individuals will severely restrict their eating out of fear of vomiting.

Diagnosis of Emetophobia

Emetophobia is defined as the specific fear of vomiting and avoidance behaviors related to vomiting situations.

In the DSM-5, it is classified as a Specific Phobia: Other type: Vomiting (SPOV).

Types of Emetophobia

There are two types of emetophobia:

  1. Those who are mainly afraid of vomiting themselves
  2. Those who are mainly afraid of others vomiting

Furthermore, people with emetophobia may be:

  1. Type 1 (anxiety-based), which refers to individuals who have an underlying anxiety condition. The anxiety leads to nausea, which then leads to more anxiety.
  2. Type 2 (nausea-based), which refers to individuals with medical conditions that cause nausea. This nausea leads to secondary anxiety and phobia, which then continues to cause more symptoms.

Differential Diagnosis

There are other conditions that may appear similar but are distinct from emetophobia such as:

Eating disorder

People with emetophobia may have trouble eating, thus they may appear to have an eating disorder.

Ask: “Are there concerns about weight/body image?”

Social anxiety

People with emetophobia may be afraid to meet with others due to fear of vomiting.

Ask: “Are you excessively shy? Do you worry about what others think? Do you worried about being embarrassed?”

Avoidant/restrictive food intake disorder (ARFID)

People with ARFID have troubles eating, often having sensory /motor issues.

Ask: “Any sensory sensitivities? Any problems with swallowing?”

Comorbidity

Common comorbidities (Lipsitz et al., 2001) include:

  • Other anxiety disorders
  • Obsessive-compulsive disorder (OCD)
  • Depression

Investigations

There are no diagnostic investigations, other than investigations to rule out a medical cause.

When and Where to Refer

Are there symptoms of emetophobia and medical causes that have been ruled out?

  • If so, consider referral to a mental health professional.

Management / Treatment: Non-Medication

Cognitive behavior therapy (CBT)

CBT explores a person's thoughts, feelings, and behaviors to help them overcome emetophobia.

An individual with emetophobia may have the following

  • Cognitive distortions, E.g. "I can't get on the bus because I might throw up!"
  • Behaviors such as avoidance of situations where they may be vomiting.

Interventions may include:

  • Cognitive restructuring:
    • Unhelpful thoughts are replaced with more positive, helpful thoughts (e.g. "I'm not going to throw up on the bus. And even if I did, it’s not the end of the world!") to allow the person to face their fears.
  • Teaching and discovering strategies that help calm and soothe the person
    • Examples include deep breathing.
  • Interoceptive exposure:
    • Many people worry that having physical symptoms will lead to vomiting.
    • As a result, the moment they experience even minor physical sensations, it may trigger the fears of vomiting.
    • In order to help with this, therapists can do interoceptive exposure exercises (i.e. exposure to stimuli produced by the body), such as spinning in circles, jumping jacks, breath-holding, running in place, and push-ups.
  • Gradual exposure
    • After creating a hierarchy, the client is gradually exposed to cues that trigger emetophobia while using soothing strategies.
    • In older case reports for emetophobia, therapists often used vomit or vomit-like stimuli.
    • This is because clients might have reported that vomiting is the most anxiety-provoking experience in their hierarchy.
    • Fortunately, more recent studies report success in treating emetophobia without vomit or vomit-like stimuli.
    • In these approaches, clients are exposed not to the vomit stimuli directly, but rather to other activities/sensations that they avoid due to vomit concerns.
    • Example
      • Is the person triggered by buses? If so, there is a very gradual exposure such as 1) thinking about buses; 2) images/drawings of buses; 3) seeing a bus from a distance, etc.

Hypnosis, or hypnotherapy

A hypnotherapist helps the person reach a state of deep relaxation, which helps the person be able to overcome the severe anxiety that normally occurs with the fear of vomiting.

Acupressure

Is there mild nausea? Some people report acupressure can be helpful for nausea.

This technique involves pressing your middle/index fingers down on the groove between the two large tendons on the inside of the wrist (National Institutes of Health, 2008).

Management/Treatment: Medications

Are there ongoing symptoms despite non-medication treatments?

  • Specific serotonin reuptake inhibitors (SSRIs)
    • Fluoxetine (Prozac),
    • Sertraline (Zoloft),
    • Citalopram (Celexa)
    • Escitalopram (Cipralex)
  • Nausea-related medications
    • Is there emetophobia plus nausea? Some individuals have reported anti-nausea medications may be helpful.
    • Examples
      • Metoclopramide.
      • Hydroxyzine (Atarax)
        • In a case report of a 15-yo female with emetophobia, anxiety and nausea, hydroxyzine was found helpful, along with an SSRI (Kannappan, 2020).

Medications can sometimes be helpful but they are not a panacea; literature is limited.

References

Boschen M: Reconceptualizing emetophobia: a cognitive-behavioral formulation and research agenda, J. Anxiety Disorders, 21(3): 407-419, 2007.

Kannappan A et al.: Emetophobia: A case of nausea leading to dehydration in an adolescent female, SAGE Open Medical Case Reports, Vol 8: 1-3.

Keyes A, Gilpin HR and Veale D. Phenomenology, epidemiology, co-morbidity and treatment of a specific phobia of vomiting: a systematic review of an understudied disorder. Clin Psychol Rev 2018; 60: 15–31.

Nausea and Acupressure, National Library of Medicine, The National Institutes of Health, Retrieved Jan 5, 2008 from http://www.nlm.nih.gov/medlineplus/ency/article/002117.htm

Van Hout, W. J. P. J., Bouman, T. K. (2006). Clinical features of emetophobia (fear of vomiting): Prevalence and comorbidity. Unpublished data.

About this Document

Written by the eMentalHealth Team and Partners.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

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Date Posted: Nov 22, 2021
Date of Last Revision: Nov 22, 2021