Specific Fear of Vomiting (SPOV)

Cynthia is a 16-year-old female who is terrified that if she were to vomit, she could choke and die. The last time she vomited was 7 years ago, at which point she got food poisoning after eating at a restaurant. Since then, Cynthia has refrained from eating at restaurants. She also frequently checks “sell by” dates on food packaging for fear that she may get sick if she eats expired food. Cynthia reports feeling nauseous and bloated almost every day of the week and is always aware of her bodily sensations that could suggest a need to vomit. When feeling this way, she takes antacids which she carries with her at all times. She believes that by refraining from eating at restaurants and paying attention to her bodily cues, she can avoid vomiting.  

What is SPOV?

Emetophobia, also known as a specific phobia for vomiting (SPOV), occurs almost exclusively in women with a prevalence rate of 6-7% (Veale, 2009). SPOV is a mental health disorder characterized by an unrealistic and persistent fear of vomiting (Keyes, Gilpin, & Veale, 2018). Individuals with SPOV are often more afraid that they may vomit than that others may vomit (Keyes, Gilpin, & Veale, 2018). The individual typically recognizes that their fear is unreasonable. They nonetheless engage in behaviors in an effort to try to avoid vomiting and these behaviors cause significant distress (American Psychiatric Association, 2013). In addition to engaging in avoidance behaviors, individuals will also participate in safety-seeking behaviors in order to reduce the likelihood of vomiting (Riddle-Walker et al., 2016). Some characteristics of SPOV along with common avoidance and safety-seeking behaviors are listed below. 

Characteristics of SPOV 

• Hyper-vigilance to nausea or other gastrointestinal sensations that might indicate threat of vomiting (Veale, 2009)
• Avoidance of thoughts and images either of themselves or others vomiting (Riddle-Walker et al., 2016)
• Avoidance of places that could have a higher threat of vomit, such as a hospital or a bar (Veale, 2009)
• Avoiding strenuous exercise (Maack, Deacon, Zhao, 2013) 
• Restriction of particular food that is associated with prior vomiting (Veale, 2009)
• Restriction of food generally in order to not feel too “full” (Veale, 2009)
• Worrying and mentally planning escape routes to vomit (Riddle-Walker et al., 2016)
• Unrealistic thoughts that an individual could stop oneself from vomiting (Riddle-Walker et al., 2016)
• Compulsive checking of “sell-by” food dates (Riddle-Walker et al., 2016)
• Excessive cooking of food (Veale, 2009)
• Excessive washing of hands or cleaning the kitchen (Veale, 2009)
• Mentally reviewing actions to reassure themselves they will not be sick (Riddle-Walker et al., 2016)

Treatment Options

While research is still in the early stages, Cognitive Behavioral Therapy (CBT) has the most evidence to support its effectiveness in treating SPOV (Keyes, Gilpin, & Veale, 2018). The first stage of any therapy is goal-setting. These goals would focus on emphasizing quality of life and reducing both avoidance and safety-seeking behavior (Riddle-Walker et al., 2016). 

Psycho-education about vomiting is often another key component in treatment. For example, one would learn that vomiting is actually an adaptive reaction when someone is truly ill, as it increases the chances that a person will survive by removing toxins from the body (Veale, 2009). An individual may also learn that vomiting does not usually last for many days like an individual with SPOV might believe. Finally, a clinician would help individuals realize that vomiting is a primitive reflex that cannot be inhibited (Veale, 2009). 

Once an individualized treatment plan is created, treatment would then focus on graded exposures. Graded exposure presents cues of vomiting to the individual without allowing them to participate in safety-seeking behavior, ultimately reducing anxiety around such cues (Veale, 2009). Exposure can happen in many different ways. An individual may first be exposed to internal cues, which may include describing details of previous episodes of vomiting or imagining the sensations associated with vomiting (Riddle-Walker et al., 2016). External cues for exposure could be things such as listening to the audio of someone else vomiting, watching a video of someone else vomiting, smelling rancid butter or parmesan cheese, or viewing actual vomit (Riddle-Walker et al., 2016). It is impractical and unethical to have clients repeatedly vomit as a form of exposure, since there are dangerous medical repercussions of doing so (Veale, 2009). Therefore exposure to vomit alone has been found to be successful in minimally reducing the phobia of vomiting to a fear of vomiting in 2/3 of clients treated in this way (Riddle-Walker et al., 2016). 

When should treatment be sought?

If you find yourself avoiding specific situations or foods in fear that you might vomit, being overly preoccupied with bodily cues that might suggest a need to vomit, and/or constantly participating in behaviors to ensure you will not vomit, then you should seek treatment from a local provider. A therapist in your area can help reduce the impact your fear of vomiting has on your daily routines, social activities, relationships, and school/work. 

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Keyes, A., Gilpin, H., & Veale, D. (2018). Phenomenology, epidemiology,co-morbidity and treatment of a specific phobia of vomiting: A systematic review of an understudied disorder. Clinical  Psychology Review, 60, 15-31.

Maack, D., Deacon, B., & Mimi, Z. (2013). Exposure therapy for emetophobia: A case study with three-year follow-up. Journal of Anxiety Disorders, 27, 527-534. 

Riddle-Walker, L., Veale, D., Chapman, C., Ogle, F., Rosko, D., Nahmi, S… Hicks, T. (2016). Cognitive   behavior therapy for specific phobia of vomiting (emetophobia): A pilot randomized controlled trial. Journal of Anxiety Disorders, 43, 14-22. 

Veale, D. (2009). Cognitive behaviour therapy for a specific phobia of vomiting. The Cognitive Behavior Therapist, 2, 272-288.