Impact on Eating When You Have a Specific Fear of Vomiting (Emetophobia)

By Carly Poynter, Psy.D. and Lauren Muhlheim, Psy.D.

Do you have a fear of vomiting? Does your fear of vomiting impact your ability to eat certain foods, in certain situations, or to an adequate level of fullness? If you have been diagnosed with a restrictive eating disorder, this phobia may drive your eating. 

You have probably heard of arachnophobia (fear of spiders), agoraphobia (fear of open spaces), claustrophobia (fear of enclosed spaces), or glossophobia (fear of public speaking), but have you heard of emetophobia? Emetophobia is the specific fear of vomiting (SPOV). It is a diagnosable disorder categorized in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, text-revision (DSM-5-TR) as specific phobia, “other” subtype.

What is Emetophobia?

Emetophobia refers to an intense and irrational (or out of proportion) fear of vomiting. It also encompasses avoidance of situations that could lead to vomiting or interacting with vomit. This specific fear of vomiting goes above and beyond a disgust for vomiting. 

People with emetophobia will often avoid food, sensations (i.e., feelings of fullness, spinning motion, etc.), and situations that they associate with vomit. Avoidance of feelings of fullness or foods related to vomiting can lead to inadequate nutritional intake. Undereating, in turn, can lead to medical consequences associated with malnutrition, significant weight loss, and/or significant impairment to occupational or social functioning. Professionals may not accurately diagnose emetophobia, mistaking it for a restrictive eating disorder, such as anorexia nervosa. 

While emetophobia and eating disorders–especially Avoidant/Restrictive Food Intake Disorder (ARFID) fear type– can occur together, it is essential to receive the appropriate treatment for emetophobia as well. 

Research on emetophobia is limited. Of what we know, emetophobia most commonly develops in childhood or adolescence and appears to impact females more than males. However, an acute onset is possible after an aversive experience, such as food poisoning or a medical issue. Emetophobia is challenging to treat due to a high drop-out rate or poor treatment response. Emetophobia may be the most common specific phobia for which people seek treatment. Left untreated, it can become one of the most impairing phobias because people with it come to avoid such a broad range of situations. 

Symptoms of Emetophobia

Symptoms of emetophobia include behaviors, thoughts, experiences of anxiety, physical symptoms, and impact on daily living.

Avoidance

Avoidance may include avoidance of sensations and situations.

Sensations Related to Vomiting

People with emetophobia may feel nauseated more frequently and experience nausea for more extended periods. The experience of nausea correlates to the severity of the phobia and contributes to greater weight loss. Sensations that people with emetophobia may commonly avoid include motion (e.g., rocking of a boat, movement in a car), the feeling of fullness or carbonation, and other similar sensations. 

Situations Related to Vomiting

People with emetophobia may avoid places and situations where they believe vomiting is more likely to occur. Situations and places may include people drinking alcohol, like bars or sporting events, medical facilities, or people who have recently been sick or around people who are ill. People with emetophobia may also isolate socially due to the fear of others being sick. 

Engaging in Safety Behaviors

People with emetophobia may engage in many safety behaviors to try to prevent vomiting. Some of these behaviors include:

• Avoidance 
• Reassurance seeking from others, including family, friends, medical providers, and the internet 
• Checking expiration dates or food recall lists
• Eating slowly or limiting the amount of food 
• Excessive body checking/ symptoms observation 
• Prematurely taking medication such as Tums, Peptobismol, or Zofran 

Disruption in Daily Life

People with emetophobia often experience impairment in their social, occupational, or medical functioning due to several factors. The fear of vomiting and the safety behaviors that people with emetophobia engage in can cause someone to become socially isolated. They may avoid social situations or even work-related duties. Alternatively, they may frequently call out sick. In addition to the social and occupational impairment, someone who is avoiding eating may suffer from the medical consequences of malnutrition. 

Thoughts Associated with Emetophobia

People with emetophobia feel terrified thinking about vomit or vomiting and experience intrusive and obsessive thoughts about vomiting. The thoughts may be related to fear of others vomiting, or the person with emetophobia vomiting, or vomit in general.  

How is Emetophobia Assessed?

The two most commonly used validated measures to assess emetophobia are the Specific Phobia of Vomiting Inventory (SPOVI) and the Emetophobia Questionnaire (EMET Q-13).

Emetophobia and Other Disorders

Emetophobia shares several symptoms and, at times, may present similarly to some other anxiety and related disorders. Illness anxiety and emetophobia share symptoms such as worrying about illness and the body, reassurance seeking, checking behaviors, and other safety behaviors aimed at preventing illness or vomiting. Some of the safety behaviors associated with emetophobia may also present as compulsive, such as hand washing, use of hand sanitizer, and checking behaviors, which are also associated with obsessive-compulsive disorder (OCD). When social functioning is impaired or social events are avoided due to this fear of vomiting, these symptoms may be mistaken for the social challenges associated with Social Anxiety Disorder. 

Emetophobia and Eating Disorders

Emetophobia and an eating disorder like anorexia nervosa, bulimia nervosa, or ARFID can co-occur. One study found that one-third of people in the survey with emetophobia also engaged in restriction and abnormal eating behaviors. In another study, 80% of individuals with emetophobia endorsed disordered eating behaviors. Another study found that 131 participants were diagnosed with comorbid anorexia nervosa. 

People with emetophobia commonly restrict the volume or type of food they eat to reduce the chances of vomiting or becoming sick. This fear-based restriction of food intake may overlap with ARFID. According to the DSM-5-TR, ARFID is an eating disorder in which individuals fail to meet their nutritional needs but lack the typical body image concerns and fear of weight gain that individuals with anorexia nervosa endorse. People with emetophobia may also meet criteria for ARFID when there is a significant fear of vomiting and eating is restricted, and any one of the following conditions is met:

• Significant weight loss or inability to maintain an appropriate weight 
• Significant nutritional deficiency
• Dependence on tube feeding or oral nutritional supplements 
• Impairment to psychosocial functioning 

Over time, individuals with emetophobia who engage in restriction of food intake may meet criteria for ARFID due to the impact on their medical or psychosocial functioning. Individuals with emetophobia may also develop symptoms of anorexia nervosa, such as concerns with their weight and shape, negative body image/ fear of weight gain, or the avoidance of more calorically dense foods. 

To ensure correct diagnosis, clinicians should attempt to understand the rationale for the avoidance of food and assess appropriately for concerns with body image and other factors that may contribute to the avoidance of food. 

How does Emetophobia Develop?

Phobias typically develop due to a combination of genetic and environmental factors. Those who end up developing emetophobia appear to have a genetic predisposition to anxiety and may experience somatic (body) symptoms of anxiety, such as nausea, heart palpitations, sweating, and other symptoms. Other genetic factors may include gastrointestinal sensitivity. Contributing environmental factors include stimuli in the environment that evoke an unpleasant response. The person views the stimulus as threatening and associates it with an undesirable response. In the case of emetophobia, someone may experience nausea after eating something and not associate that food with gastrointestinal distress. Another environmental factor is vicarious learning, such as reading or hearing about someone else experiencing the aversive reaction to a stimulus. 

How is Emetophobia Maintained?

Anxiety and avoidance behaviors (including safety behaviors) as well as hyperawareness, maintain emetophobia. 

In the emetophobia cycle depicted below, the person encounters something related to vomiting. Through a conditioned response, they interpret this as something dangerous or scary, which then increases their fear. The person then engages in safety behaviors such as avoidance or reassurance seeking, which in turn reinforces the fear of vomiting. Safety behaviors provide a false sense of control over vomiting and only offer temporary relief. 

An example could be: A person sees their friend who looks unwell and says that they are feeling nauseous. The person interprets the situation as the friend is sick and will vomit. Or they might believe the friend is ill and they are going to catch their illness and vomit. The person becomes anxious and leaves the situation, avoiding other social interactions with this friend. 

Avoidance Behaviors

Common avoidance behaviors include 

• Avoidance of certain foods that are perceived to have a greater likelihood of causing illness (i.e., meat, poultry, seafood, lettuce, uncooked/undercooked food (i.e., sushi or meat served medium rare, etc.).
• Avoidance of certain places that are perceived to have a greater likelihood of causing illness (i.e., hospitals, eating from salad bars and buffets, public toilets, traveling on planes, amusement parks, etc.).
• Avoidance of people who are perceived to have a greater likelihood of vomiting (i.e., being at bars or places with intoxicated adults, being near children who are more frequently sick, being near sick people, etc.). 
• Avoidance of conditions that are perceived to have a greater likelihood of getting sick (i.e., pregnancy, surgery, or taking medications with side effects of nausea, drinking alcohol, etc.). 
• Taking medication to reduce the likelihood of nausea at the earliest sign of gastrointestinal upset.

  

Reassurance-Seeking Behaviors

Examples of reassurance-seeking behaviors include:

• Asking others how they got sick. 
• Asking others to assure them that they will not become sick 
• Seeking medical attention 
• Googling symptoms 

Safety Behaviors 

Other examples of safety behaviors include:

• Checking expiration dates 
• Inspecting food before eating 
• Checking lists of recalled food 

Hyperawareness of Body Sensations

Heightened attention to bodily sensations also maintains emetophobia. People with emetophobia may pay more attention to their body, especially gastrointestinal symptoms, and are more likely to interpret these symptoms as nausea. Anxiety can create symptoms of gastrointestinal distress, as described above, and can be misinterpreted as a precursor for vomiting, which can increase anxiety in someone with emetophobia. 

Treatment for Emetophobia

Exposure and Response Prevention (ERP) is an evidence-based treatment approach for emetophobia. 

Pretreatment

Before beginning treatment, psychoeducation about emetophobia is provided, including information about phobias, the emetophobia cycle, the cycle of anxiety, safety behaviors, and other important information. 

You may be reassured to learn that:

• Vomiting is a normal and adaptive process. Vomiting has a functional purpose to save your life when you ingest something poisonous or hazardous
• All mammals vomit (except rats, which is why rat poison is effective).
• Vomiting is not preventable. It is a reflex that cannot be inhibited. However, diaphragmatic breathing is considered an incompatible behavior for vomiting and may help when no contaminant or illness is present. 
• People become nauseous for many reasons, and it is rarely a predictor of vomiting.
• Due to increased food safety standards, refrigeration, and sanitation in the developed world, lifetime prevalence of vomiting is considered relatively low (most people recall vomiting only four to six times over their lifetime). 

The pre-treatment phase will also include assessment of symptoms using a measure such as the SPOVI or the EmetQ-13. 

Hierarchy Creation

ERP involves creating a fear hierarchy – this involves listing situations, food, places, physical feelings, etc., in order of least anxiety-provoking to most anxiety-provoking – this can include saying vomit words, watching videos of others vomiting, creating the physical feeling of vomiting, etc. Often, you will list these on a scale from one to ten. 

Exposure

Individuals are then gradually exposed to these situations in one of three ways. 1) in vivo exposures – exposures that take place in real time, 2) imaginal exposures – imagining the situation, and 3) interoceptive exposure – exposure to the physiological sensations. Unlike many other phobias, exposures do not include forcing the individual to face the exact situation they are afraid of (vomiting). Instead, exposures focus on the sensation of vomiting through interoceptive exposures and situations that may include being around places where others are more likely to be sick or vomit, or watching videos of vomiting. 

Response Prevention

People are prevented from engaging in safety behaviors, such as escaping, checking expiration dates, and excessive sanitizing. People rate their subjective units of distress (SUDS) to communicate their level of distress during these exposures. ERP is beneficial in the treatment of emetophobia as it helps to reduce avoidance and safety behaviors that cause decreased ability to function. ERP enables the creation of new associations with previously feared situations. By contrast, when people avoid, they fail to recognize new information and disconfirm their fears or learn that they can handle the situation.

Weight Restoration

Suppose a person with emetophobia is at a low weight. In that case, weight gain and restoration of regular patterns of eating are essential treatment goals, just as it is in anorexia nervosa. Family-based treatment focused on anxiety and feeding management may be a good treatment choice for teens needing to restore weight.

Get Help for Emetophobia in California

Carly Poynter, Psy.D., Lauren Muhlheim, Psy.D., and several other of our therapists have specialized training and experience in treating emetophobia. Complete the EDTLA contact form to get connected with one of our emetophobia specialist therapists and begin your recovery.

Learn About Supporting a Loved One with Emetophobia

If someone you care about struggles with emetophobia, it can be difficult to fully grasp how intense their fear is. You might see their reactions as unreasonable and feel the urge to lighten the mood with jokes or encourage them to move past it. While they often recognize that their fear doesn’t make logical sense, simply knowing that isn’t enough to make it go away. They’re also aware that their phobia can be frustrating for you, and they often feel ashamed when it affects not just them—but those around them, too. Learn how you can support your loved one with emetophobia.

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