Could Your Eating Problems Be a Specific Phobia of Vomiting?

Eating Problems Related to Specific Phobia of Vomiting (Emetophobia)

Eating Disorders and Emetophobia (Specific Fear of Vomiting)
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Are you terrified of throwing up? Does this affect your eating? Have you been diagnosed with an eating disorder? Might your eating disorder really (or also) be a phobia?

Just like fear of flying or fear of spiders, a fear of vomiting can be so strong that it becomes a phobia. The specific phobia of vomiting (SPOV), also referred to as emetophobia, is a serious clinical condition. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) categorizes it as a specific phobia, “other” subtype.

SPOV involves an intense and irrational fear of vomiting and the avoidance of situations related to vomiting. It can look a lot like an eating disorder, and often co-occurs with one. Many people with a problematic fear of vomiting seek treatment with eating disorder therapists or at eating disorder programs. Unfortunately, it is believed that a number of people with SPOV are misdiagnosed as having an eating disorder—one study in 2013 showed that many eating disorder specialists may not know about SPOV or recognize it when they see it.

Specific phobia of vomiting has not been well researched. It affects more females than males and commonly develops in childhood or adolescence. The average sufferer is affected for 25 years before seeking treatment. Therapists generally regard SPOV as challenging to treat because of a high drop-out rate and a poor response to treatment. It can become one of the most impairing phobias because people with it come to avoid such a broad range of situations.

Symptoms and Diagnosis

There are different factors that may indicate that you have a specific phobia of vomiting.

Sensations

A core symptom of SPOV is frequent nausea, an unpleasant sensation related to the gastrointestinal system. People with SPOV feel nauseated more often than people without the phobia. Most people with SPOV report feeling nauseated every one to two days, often for more than an hour at a time. The experience of nausea appears to be closely related to the intensity of the fear that people feel. Those with SPOV who experience more nausea also seem to lose more weight.

Thoughts

If you have SPOV, you are horrified at the idea of vomiting. You may also dread losing control and being ill. When you feel sick, you may obsessively have the thought, “I am going to vomit,” with a strong belief that you will.

You may fear yourself vomiting and others around you vomiting. Most people (47 percent) with vomit phobia primarily fear themselves vomiting, and to a lesser extent fear others vomiting. A smaller number (41 percent) equally fear themselves and others vomiting. Rarely do people with SPOV only or primarily fear others (and not themselves) vomiting. Vomiting in others may be feared primarily out of fear of contagion.

Behaviors

If you have SPOV you might engage in a range of behaviors to try to reduce your likelihood of vomiting. These may include physically scanning your body for sensations and indications that you might vomit. You might also engage in safety-seeking behaviors and avoidance behaviors that include checking food expiration dates, avoiding alcohol, and avoiding certain foods like meat and seafood. These preventative behaviors can consume a great deal of worry and time.

Psychosocial Impairment

People with SPOV suffer significant impairment. It may interfere with work when you may take days off because you think someone in your office is sick. It may affect your social life when you avoid social gatherings where you believe there is an increased risk of vomiting. You may also avoid contact with children when they are ill or sleep in another room if your partner is sick or has been drinking.

Assessment Measures

There are two validated measures to assess for SPOV:

  • Specific Phobia of Vomiting Inventory (SPOVI)
  • Emetophobia Questionnaire (EMETQ)

Relation to Other Disorders

Because specific fear of vomiting shares many features in common with other more well-understood illnesses, it has likely been under-recognized and misdiagnosed. Illness anxiety disorder (formerly hypochondriasis) shares many similarities with SPOV, including worrying, reassurance-seeking, and checking behavior about possible infections or food poisoning that could lead to vomiting.

The symptoms of SPOV can look like the compulsive handwashing or sanitizing observed in obsessive-compulsive disorder (OCD). Both SPOV and panic disorder are characterized by an overfocus on and fear of bodily sensations, which in turn intensifies the sensations. Some patients with SPOV have some of the symptoms of social phobia, with fear of vomiting in social situations or of others judging them if they get sick.

Relation to Eating Disorders

While diagnoses of an eating disorder and SPOV can co-occur, there is limited research on how frequently this happens. In one study of eating behavior in people with SPOV, approximately one-third of participants restricted their food and engaged in abnormal eating behavior. Another study found that 80 percent of individuals with SPOV reported abnormal eating behavior and 61 percent reported food avoidance. In a third study, of 131 patients with SPOV, four were also diagnosed with anorexia nervosa.

People with SPOV often restrict food to reduce the risk of vomiting. As such, they may look a lot like patients with eating disorders, specifically avoidant restrictive intake disorder (ARFID), which the DSM-5 defines as an eating disorder in which individuals fail to meet their nutritional needs but do not have the typical body image concerns of individuals with anorexia nervosa. People with SPOV can also meet criteria for ARFID when there is an extreme fear of vomiting and eating is restricted and any one of the following conditions are met:

  • Significant weight loss
  • Significant nutritional deficiency
  • Dependence on tube feeding
  • Psychosocial impairment

Over time and with dietary restriction, some people who have SPOV that meets ARFID criteria can also start to develop features of anorexia nervosa, such as weight and shape concern, negative body image, or the avoidance of calorically dense foods.

It also appears likely that some individuals with SPOV may be misdiagnosed with anorexia due to eating-disordered attitudes and behaviors that are driven by phobic fears rather than eating psychopathology. When making a differential diagnosis clinicians must understand why a patient fears and avoids food: is it because of fear of weight gain or fear of vomiting?

Development

Phobias are believed to be caused by a complex interplay of genetic and environmental factors. There are believed to be several predisposing factors for SPOV. People who develop a fear of vomiting appear to have a general vulnerability to anxiety. They may tend to express anxiety through somatic symptoms such as “butterflies in the stomach” or nausea. Finally, they may have high disgust sensitivity.

Many phobias involve some learned fear that activates these predisposing factors. Some traumatic incident may have contributed to the phobia’s development. Many individuals with SPOV recall a triggering incident involving themselves or others vomiting. Some individuals recall no triggering incident; these may be cases of vicarious learning, for example reading about an incident of vomiting or hearing someone else talk about vomiting in a fearful way.

Maintenance

The more people pay attention to gastrointestinal symptoms, the more likely they can perceive nausea. Those who experience anxiety physically can catastrophically misinterpret the benign signs of digestion as an indicator of upcoming nausea. This leads to increased anxiety, which heightens nausea.

This feeling can be mistaken for the warning sign that vomiting is imminent. This catastrophic misinterpretation serves to increase anxiety, and the vicious cycle continues. The more nausea a person feels, the more fear they have, the more hypervigilance, the greater nausea.

Avoidance and safety behaviors also maintain the phobia. People with SPOV often avoid specific foods out of fear of vomiting. Commonly avoid foods include meat, poultry, seafood and shellfish, foreign meals, dairy products, and fruits and vegetables. They may restrict the amount of food to reduce sensations of fullness which they fear could lead to vomiting. They may also restrict eating food in certain contexts, such as food cooked by other people.

People with vomiting phobia may come to avoid a broad spectrum of situations:

  • Those they believe will increase their own risk of vomiting—eating from salad bars or buffets, visiting people in the hospital, eating at restaurants, public toilets, traveling, boats and airplanes, going to an amusement park, or meeting ill people
  • Those where they believe they may see someone vomiting—events where guests drink alcohol, places where children play— or where they fear they may vomit in the presence of others
  • Pregnancy—some have even chosen to terminate a pregnancy because of their fear of vomiting
  • Recommended surgery

It should be noted that most of these situations avoided would be associated with an extremely low risk of vomiting. As a result, people who avoid them fail to learn that these situations are not dangerous.

People with SPOV develop safety behaviors they believe reduce their likelihood of vomiting. They may take antacids, wear rubber gloves, repeatedly check the sell by date and the freshness of food, wash their hands excessively, inordinately clean the kitchen area, and wash food excessively. They overestimate the efficacy of these measures in preventing vomiting.

It is helpful for people with SPOV to understand that frequency of vomiting is not much different for people with SPOV than it is for people who do not have the phobia and do not practice avoidance and safety behaviors. In reality, vomiting is a rare occurrence.

Treatment

Research on treatment for SPOV is very limited, with only one published randomized controlled trial. cognitive-behavioral therapy (CBT) is the most widely used approach for the treatment of SPOV and other phobias. Treatment must begin with a thorough assessment and a formulation that helps the patient to understand the processes that maintain the patient’s fear. The formulation also guides the selection of treatment targets.

As with most phobias, exposure is a central aspect of the treatment. A key difference in the treatment of SPOV is that treatment does not usually include exposure to the exact situation—that is, making oneself vomit. Induction of vomiting via an emetic is not considered practical or safe, particularly when done repeatedly. Also, a single exposure might not be sufficient to reduce the awfulness of vomiting. Treatment focuses instead on exposure to the sensations associated with vomiting and the situations that trigger a fear of vomiting.

Psychoeducation

CBT for SPOV usually begins with psychoeducation about vomiting phobia, including a cognitive model of anxiety emphasizing the interplay of cognitive, physical, and behavioral factors. Patients should be educated about factors that maintain the disorder and the importance of exposure in the treatment.

You may be reassured to learn that:

  • Vomiting is a normal and adaptive process, designed to save your life by ridding your body of something you have ingested that is contaminated or poisonous.
  • All mammals except rats vomit (which is why rat poison is effective).
  • You cannot prevent yourself from vomiting. It is a primitive reflex that cannot be inhibited.
  • Nausea is only rarely an indication of vomiting.
  • Food safety standards, refrigeration, and sanitation have substantially reduced the instance of vomiting in the developed world; one study found that most people can recall vomiting about four to six times over their lifetime.

Exposure

The treatment of emetophobia often includes exposure to the physical sensations central to the experience and maintenance of SPOV, such as nausea. Exposure to physical sensations involves inducing physiological symptoms that are similar to anxiety. For example, having a patient spin can often induce dizziness and sometimes nausea.

Some CBT treatment models include imaginary rescripting of past aversive experiences of vomiting. Some therapists use exposure to videos of others vomiting. Sometimes patients are asked to fake vomit. In this exercise, they put a concoction of diced food in their mouth, kneel in front of the toilet, and spit into the toilet to simulate the texture and sounds of vomiting. Patients can also be exposed to a substance that looks or smells like vomit.

In addition to exposure to physical sensations and to aspects of vomiting described above, treatment should include exposure to all foods and situations that have been avoided. This is often done in a hierarchical fashion, with progressively scarier situations approached over time. Situations can be combined. For example, a person may eat a fear food and then go on a rollercoaster.

CBT treatment also includes discontinuing safety behaviors, such as wearing gloves and excessive cleaning. It also includes challenging anxiety-provoking thoughts.

Although cognitive behavioral interventions would clearly be the focus, certain medications such as SSRIs might be helpful, particularly if there are other mood or anxiety symptoms. 

Weight Restoration

If the patient is at a low weight, then weight gain and restoration of normal patterns of eating in SPOV is an important treatment goal, just as it is in anorexia nervosa. Family-based treatment focused on nutritional restoration and exposure may be a good treatment choice for adolescents with SPOV needing to restore weight.

A Word From Verywell

It is common to feel reluctant about seeking help. If you (or a loved one) have a severe fear of vomiting, it is important to receive an assessment leading to an accurate diagnosis. Then you can begin the process of recovery.

Sources:

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