Emetophobia Research (Phobia of Vomit / Fear of Being Sick)

Hi Folks

On this page I’m going to list some of the research papers I found useful when developing my ‘cure your emetophobia and thrive’ programme.  For legal/copyright reasons I can’t reproduce the whole papers, but I’ll provide the reference should you wish to get the full paper yourself.  I’ll also list any useful quotes, and give some info on why I thought the paper was useful.  Most of these papers made it into the book.

Competence Imagery: A Case Study Treating Emetophobia
(Moran & O’Brien, 2005)

This paper describes the case of an 11-year-old girl with emetophobia, who had not responded to desensitisation therapy. Here they used ‘competence imagery’  (competence imagery = imagining/rehearsing success – as per the action in the Coue’s Law section of my book) The paper contains a useful graph which indicates that as the girl felt more competent (i.e. powerful), her obsessing decreased.

Quote 1: The Competence Imagery treatment included systematically pairing anxiety-provoking CS (video scenes of someone vomiting), while desensitizing the anxiety response with competence images (p. 635)) with the girl, which was successful. The competence imagery essentially used an affect bridge – imagining a time when felt competent in any area, whilst being exposed to a situation where person normally created anxiety.

Quote 2: An 11-yr.-old girl avoided social environments because she feared encountering vomit. She also had high to moderately obsessive thinking about encountering vomit. Her initial Yale- Brown Obsessive Compulsive Scale score was 14, tallied exclusively from the Obsession scale. (p. 635)

Scared to Lose Control? General and Health Locus of Control in Females With a Phobia of Vomiting
(Davidson, Boyle, & Lauchlan, 2008)

Quote 1: Having studied the anecdotal reports of members of an online support group for emetophobia (Listserv, 2003), it appears that many report a fear of losing control, which may underlie their emetophobia. The present research aimed to investigate an association between emetophobia and an internal locus of control. Emetophobics may be different from those with other anxiety and depressive disorders in that emetophobics may have an internal locus of control. This internal locus of control may serve to maintain their emetophobia by contributing to a fear of losing control. It was hypothesized that emetophobics would have an internal locus of control, contrary to other anxiety and depressive disorders. (p. 30)

Quote 2: Participants were administered the Rotter (1966) Locus of Control Scale and the Health Locus of Control Scale by B.S. Wallston, Wallston, Kaplan, and Maides (1976). Significant differences were found among the three groups; specifically, that emetophobics had a significantly higher internal Locus of Control Scale score with regard to both general and health-related issues than did the two control groups. It is suggested that vomiting phobics may have a fear of losing control, and that their vomiting phobia is reflective of this alternative, underlying problem. More research is required to explore the association between emetophobia and issues surrounding control; however, the current study suggests that it may be helpful for therapists to consider this aspect when treating a patient with vomiting phobia. (p. 32)

Media Hype, Diagnostic Fad or Genuine Disorder? Professionals’ Opinions About Night Eating Syndrome, Orthorexia, Muscle Dysmorphia, and Emetophobia
(Vandereycken, 2011)

Looks at professionals (psychologists, psychiatrists, nurses and social workers) views on a number of disorders, including emetophobia. It aimed to explore their familiarity with the disorder as well as whether they saw it as a genuine syndrome or a diagnostic fad, created by media hype.
For emetophobia the percentage of respondents agreeing to the following statements was:
Totally unknown to me: 29.7
Observed in my own practice: 48.6
Created by popular media: 4.5
Variant of another disorder: 31.5
Deserving more attention: 61.3

Quote 1: …almost half of the professionals have seen cases in their practice and here the popular media were supposed to have practically no influence on shaping this disorder. (p. 150)
Quote 2: The most surprising result is the professionals’ opinion about Emetophobia: a disorder on its own, often observed in clinical practice but too much neglected in the scientific press. (p. 150)

Return Of Fear In The Treatment Of A Fear Of Vomiting
(Philips, 1985)

This paper explored an exposure treatment with seven emetophobes. The study found that many of the emetophobes had other problems as well.

Quote 1: Over two-thirds of these phobics had other difficulties as well, though they felt them to be of less importance. These ‘secondary’ problems were: mild depression, other phobias, social anxiety, homosexual concern, obsessional concerns, agoraphobic symptoms, anorexic symptoms and classic migraine headaches. The average Beck Depression Inventory (BDI) score was 10.9-thus placing the group at the cut-off for borderline depression. (p. 46)

It appeared that the emetophobes responded to the treatment in different ways.  There appeared to be two groups, one whose fear gradually decreased over the course of the treatment and one whose fear was slower to reduce, because although fear was reduced after each session, it returned between sessions.

Quote 2: Looking at the within-session changes, it appears that the slower patients (in Group B) were delayed, not because of slower within-session habituation gradients, but because of a repeated return of fear which was manifested by high initial levels at the onset of each new session. This tendency was observed in response to auditory and to visual cues. The remarkable feature is not the similarity of the habituation curves of the two groups, but the marked return of fear in only one of them. (p. 50)

Quote 3: Therefore, it seems possible that the return of fear found in one subgroup might have been a function of higher levels of depression (pretreatment), and/or auditory phobic stimuli being provokers of increased depressive feelings during treatment. Possibly the latter occurs as a function of complex memories being re-evoked. One implication of this is that exposure and response prevention techniques, as well as allowing habituation processes to occur to anxiety stimuli, may also allow emotional processing of other associated material. (p. 50)

Quote 4: it would also be predicted that more sessions would be needed to fully habituate the anxiety in a group in whom traumatic onset phobias were present, as opposed to those individuals who report no traumatic onset and a gradual increase in anxiety in relationship to a certain stimulus. Finally, in Ss who show high initial reactions and a tendency for return of fear to occur on subsequent sessions, it may be necessary to prolong sessions and thus allow repeated exposure to phobic material even when no further anxiety is evoked. This would allow further processing of associated emotional material provoked by the stimuli. It is predicted that increasing the number of stimulus presentations will reduce the return of fear phenomenon, even when these presentations are no longer provoking anxiety. (p. 51)

You Don’t Have to be Sick to be a Behaviour Therapist but it can Help! Treatment of a “Vomit” Phobia
(McFadyen & Wyness, 1983)

This study basically discusses how exposure therapy can be helpful in treating emetophobia.
It describes a case study with one woman, who had a fear of others vomiting. The therapist simulated being sick over a number of sessions and the woman’s fear gradually decreased. 18 months later she was continuing to report improvements.

Quote 1: The exposure sessions had shown her that she did not have to worry about what would happen if she could not get away; the worst was that it would be very uncomfortable, but nothing more than that. (p. 175)

Why Can’t I Get Hives: Brief Strategic Therapy with an Obsessional Child
(O’Connor, 2004)

This paper explores a case of emetophobia in a 10 year old boy, Michael.

Quote 1: The thought or word “vomit” would flood him with panic and fear. He would then experience an intense stomach ache, headache, cold sweat, and incapacitation from one to three hours. These episodes occurred most frequently at school, where these feelings would “overtake” him. (p. 2)

Michael is also described as having or having had other obsessional problems prior to his referral in the paper.
The paper is interesting in terms of demonstrating parents as ‘significant others’ with children with emetophobia:

Quote 2: A typical sequential pattern involved Michael ritualistically and repeatedly seeking reassurance in the morning from his mother and father that he would not vomit. Michael’s request would result in parents escalating their comforting statements, and neither parent could mention the word “vomit” in their encouragement. Father would call Michael from work, providing reassurance over the phone. Michael would state that if his father told him he would not vomit, he felt sure he would not.
Prior to referral, episodes of school refusal were common. At school, Michael was allowed to go to the school nurse and lie down, but despite the nurse’s reassurances that he would not vomit, Michael’s mother would invariably come to school and take him home. These episodes were occurring twice a week at the time of referral.
Michael would also obsess when his parents left the house. Efforts by his parents to get away to a movie, for example, were countered by Michael’s vigorous protest and fear, and he would sit by the clock and cry, despite a sitter’s presence. Michael feared they would never return or would die (“That’s why I hate for you two to go out alone.”), which reflected an obsessive child’s typical preoccupation with death and decay. Parents did not allow themselves to be away for more than two hours because of Michael’s distress, promising they would be back at the designated hour. Michael was an only child.

Quote 3: A history of extensive medical tests on his digestive system revealed no significant medical problem. In the past two years, Michael had actually vomited once during an illness and was not particularly distressed or repulsed. He was described as a fragile child by his parents, plagued with allergies, always sick with a cold, stomach ache, or headaches. He was seen by them as an anxious child, always fidgeting, biting his nails, and spending most of his time indoors. He would build models and collect coins, but he did not participate in sports. He did well academically. He reported having a few friends and was apparently liked by peers and teachers in school, but peer relationships were depicted as fairly superficial. During the summer prior to referral, he was allowed to cross the “big street” and visit his friends in their territory. Michael experienced a good summer with no complaints, and somatic difficulties were almost nonexistent. (p. 2)

Quote 4: Mother smiled and agreed that she had been extremely overprotective when he was young, and she assumed the blame for his current obsessional style. She indicated she now wanted Michael to try to do more things on his own, but “Now he doesn’t want to.” She said that she did not let him get dirty when he was younger and indicated she was afraid of “germs.” (p. 2)
Quote 5: Second, within this view of problem maintenance, Michael’s reporting of his obsessions to his parents precipitated a circular, homeostatic parent-child loop of reassurances, complaints, reassurances, and so forth. Parental reassurances were never enough to diminish completely Michael’s anxiety. The family was organized and regulated by Michael’s descriptions of feeling states, which sequentially evoked a series of verbal reassurances by parents. Michael would continue his visceral monitoring, report changes, and parents would increase their reassurance. In this way, the parents’ behaviors in finding a solution became part of the symptom-maintaining matrix. (p. 4)

It also describes some of the other potential causal/ maintaining factors

Quote 6: The problems can be described as (a) Michael’s obsessing, which indeed caused him much personal anguish and interfered with his schooling, home life, and personal development, and (b) his reporting of the obsessions to his parents, which engaged a dysfunctional, homeostatic cycle of family interactions. Because Michael psychologically equated thought and action, his obsessions can be viewed as two similar problems: his fear of vomiting, but more centrally, his fear that he could not stop thinking about vomiting. His fears were self-perpetuating; by thinking about how much he thought about vomiting, he would become alarmed that these thoughts could occur during circumstances over which he would have no control e.g., at school, at home if his parents were out, etc., Michael was engaged in an elaborate but ineffective program to delay facing the fear by constantly preparing to face it (4). His solution was to prepare for thoughts of vomiting in such a way that these thoughts (and his fear) would be mastered in advance by seeking solicitations from his parents, avoiding certain words, and ritualizing the morning conversation. Attempts to distract himself and not think led to major and magical efforts at self-deception that were ineffective. (p. 3)


Treatment of a woman with emetophobia: a trauma focused approach
(Jongh, 2012)

This paper, firstly, contains some useful background information on emetophobia.

Quote 1: A phobia of vomiting, or emetophobia, is a condition characterized by a disproportionate fear of vomiting or other people vomiting, and is generally associated with an overwhelming sense of losing control, becoming very ill, or that others will find them repulsive. Individuals with this condition have a tendency to check and monitor interoceptive stimuli such as nausea that in turn makes them more likely to feel sick.1
Estimates about the prevalence of emetophobia suggest that it is a rare condition occurring in about 0.1% of the population.2 Conversely, in its milder form, fear of vomiting is fairly common in the community with estimates of point prevalence rates ranging from 3.1 to 8.8%, and women being four times more likely to suffer from fear of vomiting than men.3,4
Emetophobia belongs to the category of specific phobia (Other Type) according to the current edition of the Diagnostic and Statistical Manual of Mental Disorders.5 To be diagnosed with emetophobia, the avoidance response must be very distressing and have a significant impact on the person’s life. As a result, emetophobics have a tendency to avoid a wide array of situations or activities that they believe might increase the risk of vomiting. For example, they may avoid crowded places from which they fear they cannot quickly escape in case of nausea or vomiting, such as shops, boats, airplanes, concerts and hospitals. In addition, they may not be able to go on holiday or travel on public transport, but the avoidance behavior could also pertain to avoiding adults or children who may be ill (and, therefore, regarded as contagious) or who are at risk of vomiting (e.g. people who are drunk). The avoidance might extend to using public toilets or door handles, medication, going to the dentist, restricting the activities of their children who may be in contact with other children, or to certain food which they believe could cause vomiting, which may lead to being significantly underweight.4,6,7
The sudden nausea and anxiety in emetophobia seems to have many similarities with panic disorder8 and agoraphobia.6 The difference between emetophobia and panic disorder, however, is that the panic caused by emetophobia is usually of much shorter duration than that of panic disorder. Furthermore, the avoidance behavior of emetophobics covers a much wider range of situations than seen in agoraphobia, including the avoiding of drinking alcohol, becoming pregnant, contact with sick people and people with a degree of unpredictability, like children or the mentally handicapped.6 More specifically, the behavior of emetophobics is primarily aimed at the prevention of nausea and vomiting and not, as is the case of agoraphobia, to avoid situations where the thought comes to mind of not being able to get help when misinterpreting bodily signs of anxiety.
If left untreated, emetophobia is likely to persist. Knowledge on how emetophobia should be treated is limited, partly because of the lack of any controlled trial on the (relative) efficacy of treatment strategies for this condition. In fact, there are only a few published cases in the literature. (p. 10)

Quote 2: emetophobics frequently report a childhood onset, often following exposure to distressing experiences of vomiting or seeing others vomit 6 (p. 10)

The paper explored the case of a 46-year old woman with emetophobia.

Quote 3: …had been suffering from an excessive and unreasonable fear of vomiting for as long as she could remember. She had always done everything in her power to avoid seeing other people vomit, including her own children, as she was afraid that it would make her want to throw up herself. Debbie, therefore, avoided all kinds of situations, among which visits to hospitals, and watching certain television programs and films, from fear of seeing people that might feel unwell, and who therefore might vomit. Because Debbie had gradually been avoiding more and more of these situations in her daily life, her world had shrunk considerably. (p. 11)

Quote 4: EMDR is a protocolized, 8-phase psychotherapeutic approach aimed at resolving symptoms resulting from disturbing and unprocessed life experiences.27 It begins with a focus on the traumatic memory itself by asking the client to recall the memory and to concentrate on various aspects of it. The client must focus specifically on the most distressing image and a dysfunctional negative belief of oneself in relation to the image, as well as accompanying emotions and bodily sensations. A core feature of the procedure is the performance of eye-movements. Typically, the therapist moves his or her fingers back and forth in front of the client, asking him or her to track the movements with the eyes while concentrating on the trauma memory.27 Following the image and negative cognition (NC), access to the emotional and somatic aspects of the memory takes place. After each series of eye movements (termed a set) the client is asked to report emotional, cognitive, somatic and/or imagistic experiences until internal disturbances reach a SUDs (subjective unit of disturbances scale ranging from 10 to 0) of zero and adaptive and positive cognitions (PC) are rated strong on a VoC (validity of cognition) scale, ranging from 1 (feels completely untrue) to 7 (feels completely true). For the application of EMDR with phobias, there are a number of elements added to the procedure, including a preparation for future confrontations with the phobic stimulus.28 (p. 11)

Three years post treatment, although the woman still did not like seeing someone vomit, she didn’t have a panic reaction.

Emetophobia: Preliminary Results Of An Internet Survey
(Lipsitz, Fyer, Paterniti, & Klein, 2001)

This paper describes an Internet survey of emetophobes, which aimed to explore the disorder.

Quote 1: Results suggest that, for this sample, emetophobia is a disorder of early onset and chronic course, with highly persistent and intrusive symptoms. Emetophobia is implicated in social, home-marital, and occupational impairment and it causes significant constriction of leisure activities. Nearly half of women avoided or delayed becoming pregnant. About three quarters of respondents have eating rituals or significantly limit the foods they eat. Respondents describe other problems such as depression, panic attacks, social anxiety, compulsions, and frequent history of childhood separation anxiety. (p. 149)

Quote 2: Respondents (n=56) were 89% female. They ranged in age from 14 to 59 years (mean=31.4; SD=9.7) (p. 150)

Quote 3: Duration and persistence. Respondents portrayed emetophobia symptoms as early in onset, chronic in course, and high in persistence. Mean age of onset was 9.2 years (SD=5.0; range = 4–32 years of age). Mean duration at the time of the survey was 22 years (range = 2–54 years of age; SD=11.4). Twenty-nine respondents (52%) denied having even brief periods of remission of symptoms. Twenty (36%) had partial or brief remissions. Only seven (12%) described periods of full remissions of emetophobia symptoms lasting 6 months or longer. Over 90% of respondents said they experienced distress from emetophobia symptoms 52 weeks a year. Over 70% said they were distressed 6 to 7 days a week. Some reported that distress lasted only a few minutes at a time, while for others distress was constant (e.g., “nearly every waking moment”). Eighteen (32%) said they felt distress during most of their waking hours. (p. 150)

Quote 4: Self vs. others vomiting. Nearly two thirds of respondents (n=35) were more fearful of vomiting themselves than of seeing others vomit. Eighteen percent (n=10) said they were more fearful of seeing others vomit. Twenty percent (n=11) said they were equally fearful of both scenarios. (p. 150)

Quote 5: Triggers. Almost all respondents said that feelings of fear were triggered by both external stimuli (e.g., sight of food) and internal sensations (e.g., acid stomach). Mean percentage of time fear was triggered by external stimuli was highest (45.2%; SD=26.7), followed closely by internal sensations (40.5%; SD=26.3), with fear coming “out of the blue” seen as less common (15%; SD=19.5). (p. 150)

Quote 6: Public vs. private. Nearly two thirds of respondents (62%) said they were more worried about vomiting in a public place. About a third (34%) said they were equally anxious about vomiting in a public or private place. Only two respondents (4%) said they were more anxious about vomiting in a private place. Many respondents who were more fearful of vomiting in public also volunteered that they were fearful of vomiting in private. Respondents who feared vomiting in public were more likely to respond that they had problems with social anxiety (29% vs. 5%, χ2=4.71,P=.04). (p. 150)

Quote 7: Panic attacks. Half the respondents (n=28) answered yes to the question of whether they experienced panic attacks that had “no relationship to (ongoing) fear of vomiting.” The most frequently mentioned panic symptoms were nausea (82%), shortness of breath (62%), and gastric distress (57%). (p. 150)

Quote 8: Comorbidity. Respondents described other mental health problems they experienced in present or past. Since no clinical assessment was conducted, these reports reflect participants’ own understanding of their difficulties, which may or may not be based on diagnoses given by clinicians. Thirty percent said they were fearful of other specific things (e.g., insects) to which they react with disgust. Forty percent said they had “panic disorder” or “agoraphobia;” 46% said they had “depression;” 21% reported problems with social anxiety, and 18% said they had “obsessive compulsive disorder” (OCD). Fifty-seven percent (n=32) described past symptoms of childhood separation anxiety disorder (CSAD). With the exception of CSAD symptoms, emetophobia typically preceded these other problems (p. 150)

Quote 9: Treatment response. Nineteen (34%) respondents felt they had partial benefit from medications. Nine (16%) benefited from psychotropic medications, which included benzodiazepines and antidepressants. Others said they benefited from gastrointestinal medicines (e.g., Phenergan and Zantac). Many said they avoided trying medications for fear that these would make them nauseous. Six respondents (11%) said they had partial benefit from psychotherapy. A few patients described having behavior therapy or hypnosis for emetophobia with no benefit. A few individuals in psychotherapy for other reasons said they were too ashamed or anxious to discuss emetophobia with their therapists. In general, respondents seemed sceptical about the usefulness of psychotherapy. Only six said they would be willing to try an exposure therapy that included exposure to vomiting sensations. Thirty (54%) said they would definitely not try this and twenty (36%) were unsure or said they would consider it if it was guaranteed to work. (p. 150)

Quote 10: Impairment. Thirty-five respondents (62%) gave examples of social impairment (e.g., avoiding parties where there might be alcohol). Nineteen (34%) gave examples of impairment in home-marital functioning (e.g., difficulty being left alone with young children). Eleven (19.6%) gave examples of impairment in occupational functioning (e.g., having to leave work frequently for fear of vomiting). Five (9%) described impairment in school (e.g., skipping class). Seventy percent (n=39) described significant constriction in leisure activities. The most commonly avoided activities involved modes of travel (e.g., buses, airplanes, and car trips) or venturing to new unfamiliar places. Twenty-two female respondents (44%) said they had avoided or delayed becoming pregnant because of fear of vomiting; 12 others (24%) said they feared pregnancy for this reason but this had not affected their plans. Six other women (12%) said that emetophobia had made their pregnancies especially distressing.
Three quarters of the respondents (n=42) said they had rituals around eating (e.g., excessive washing or repeated checking for freshness) or had significantly limited the way they eat or the type of foods they eat. Many volunteered that they do not eat outside of the home or eat only from a list of “safe foods.” A few respondents expressed concerns about having poor nutrition and being underweight because they were too worried about what they eat. Twenty-four respondents (43%) said they avoided using the word vomit for fear that this would trigger images or sensations of vomiting. In correspondence in this support group, individuals typically use the letter “v” to refer to vomiting. (p. 150)

Quote 11: Conditioning experiences. Sixteen respondents (29%) recalled having severe or vivid bouts of vomiting, although in four of these cases fear of vomiting reportedly preceded the vomiting experience. Thirty-three respondents (59%) recalled vivid experiences in which they witnessed others’ vomiting. In some cases these were repeated exposures to relatives, including parents, who were ill, pregnant, or alcoholic. Eleven respondents (20%) had distressing experiences both of vomiting on their own and of observing others. (p. 151)

Quote 12: Medical history. Eleven respondents (20%) had been hospitalized overnight in childhood. Seven of those (above) who recalled vomiting experiences had also been hospitalized and vomited from illness or in response to medical procedures (e.g., anesthesia).
Others were hospitalized for common childhood problems (tonsillectomy and broken leg) with no clear connection to vomiting. About 30% of respondents said they had experienced a serious medical problem in adulthood, the most common which were endocrine disorders (n=4), gastrointestinal disorders (n=3), and asthma (n=3). (p. 151)

Quote 13: Family history. Excluding two respondents who were adopted, 57% (n=31) said at least one first-degree relative had been diagnosed with a psychiatric disorder. The most common disorders reported in relatives were panic disorder (n=11), depression (n=9), and OCD (n=5). Four respondents (7%) said that first degree relatives had emetophobia. (p. 151)

Quote 14: Unfortunately, little is known about the prevalence of emetophobia. Case reports [e.g., Phillips, 1985] are rare. An unpublished report [Kirkpatrick and Berg, 1981] found fear of vomiting to be at the “extreme or terror” level in 3% of men and 6% of women in a non-psychiatric sample. However, it is not clear how many of those people might have significant distress or impairment from their fear. (p. 151)

The Psychopathology of Vomit Phobia
(Veale & Lambrou, 2006)

In this paper a survey was conducted on self-diagnosed vomit phobics compared to panic disorder and non-clinical controls. It gives some useful background info on emetophobia, as well as explores some of the causal and maintaining factors.

Quote 1: Vomit phobics were overwhelmingly female and had had symptoms for over 25 years. They were significantly more likely to fear themselves vomiting (in public and private situations) than fear others vomiting. The vomit phobics interpreted sensations of nausea as impending vomit and had a wide range of safety seeking and avoidance behaviours that were maintaining their fear. Although the vomit phobics reported feeling nauseous more often, there was no difference in their frequency of vomiting compared to the control group. (p. 139)

Quote 2: A specific phobia of vomiting (also known as emetophobia) is a greatly under-researched area. Cases of vomit phobia have been described as presenting as anorexia nervosa (Manassis and Kalman, 1990), but generally little is known about the phenomenology or treatment. Compared to other specific phobias, clinicians generally regard it as challenging to treat because of high drop out or a poor response to treatment. (p. 139)

Quote 3: The mean age of onset in the vomit phobic group was 9.8 years old (SD 6.9) and it was described as first becoming a problem at 11.6 years old (SD 7.2). The mean duration of vomit phobia was 25.9 years (SD 13.9; range 4 years to 65 years). (p. 141)

Quote 4: The majority (77.6%) of the vomit phobics did not discriminate between the fear of vomiting whether they were alone or in public situation. A minority (16.3%) feared vomiting mainly in public and social situations. (p. 141)

Quote 5: Forty-seven percent of vomit phobics feared themselves and others vomiting equally, and 41% feared mainly themselves vomiting and had some fear of others vomiting. (p. 142)

Quote 6: There were no significant differences between the clinical groups in the number of times they believed they had vomited in their life (mean for vomit phobics 4.71 vs. panic disorder 3.58) (F(2,33)=1.373, p<.268) or in the number of times they had been ill (mean for vomit phobics 2.47 vs. panic disorder 1.50) (F(1,18)=0.789, p<.389). Therefore, despite spending their life preventing themselves from becoming sick, the frequency of vomiting was not significantly greater in individuals with vomit phobia compared to the panic disorder group. (p. 142)

Quote 7: Vomit phobics reported feeling nauseous significantly more often than the panic disorder group (Chi-squared = 23.123, df = 7, p<.002). The majority of the vomit phobics reported feeling nauseous almost every day or every other day (vomit phobics 51% v panic disorder 22%). When the two groups felt nauseous, the feeling would also last for a significantly longer duration in the vomit phobics compared to the panic disorder group, as 78% of the vomit phobics felt nauseous for more than an hour a day compared to 41% of the panic disorder group (Chisquared = 17.543, df = 5, p<.004). (p. 142)

Quote 8: Both clinical groups completed the Beck Anxiety Inventory (Beck et al., 1988). The mean score in vomit phobics was significantly higher compared to panic disorder (33.6 vs. 20.9)(F (1,114) = 14.98, p<.0001). (p. 143)

Quote 9: Vomit phobics reported significantly higher mean probabilities of most of the events occurring compared to both the non-clinical controls and the panic disorder group. For three events, vomit phobics rated significantly higher probability ratings for choking, dying and fainting compared to non-clinical controls but not the panic disorder group. (p. 144)

Quote 10: For the degree of awfulness of vomiting, five events revealed significant differences between the clinical groups (Table 5). The vomit phobics rated the degree of awfulness of losing control; of becoming ill; of others finding them repulsive; and of others not wanting to know them as significantly higher than the panic disorder group. (p. 144)

Quote 11: Both clinical groups completed a modified version of the Safety Behaviours Questionnaire (Salkovskis et al., 1999) that asks about their behaviour when they felt sick. Vomit phobics were more likely to report looking for an escape route (F(1,119) = 18.18, p<.00001); trying to keep tight control of their behaviour (F(1,121) = 15.11, p<.0001; taking medication (F(1,120) = 15.96, p<.0001); reading (F(1,118) = 16.16, p<.0001); sucking antacids/mints (F(1,118) = 17.07, p<0.0001) and moving very slowly (F(1,122) = 10.8, p<.001).Consistent with their psychopathology, the only safety seeking behaviour panic disorder patients were significantly more likely to report was physically checking the body (e.g. heart rate). Insignificant differences between the two clinical groups included distracting behaviours such as trying to think about other things, do more physical exercise, focusing attention on their body, eating something, sucking on ice, going to bed, asking people around for help and holding onto or leaning on someone.
Additional safety seeking behaviours reported by the vomit phobics included repeatedly checking the sell by date and the freshness of the food (29%); washing hands and brushing their teeth excessively (16%); checking the health of themselves and of others (16%); superstitious behaviour such as “not stepping on a 13th stair” or repeating a word or action a certain number of times to prevent vomiting (14%); seeking reassurance from others (12%); excessively cleaning of the kitchen area with products such as Dettol and anti-bacterial sprays (10%); washing food excessively (8%) and eating sweets (5%).(p. 144)

Quote 12: Vomit phobics avoided a wide range of situations or activities because of their fear of vomiting. The most commonly avoided activities when alone included: illegal substances (92.3%); being around drunks (89.2%); fairground rides (86.9%); people who are ill (82.2%); boats (89.3%); holidays abroad (72.6%); travel by aeroplane (68.7%); drinking alcohol (66.1%); crowded places (65.1%); public transport (64.4%); eating from salad bars or buffets (63.1%); visiting others in hospital (56.8%); pubs (55.65%); eating at restaurants (54.1%); public toilets (51.5%). There were no significant differences whether they were alone or accompanied by others.
In an open question, vomit phobics were asked if they avoided any specific foods because of their fear of vomiting. The most commonly avoided foods included: meat (54%) (poultry in particular); seafood and shellfish (51%); foreign meals (particularly curries) (36%); dairy products such as soft cheese, milk and ice cream (24%); fruit and vegetables (24%); fried fast food (21%); eggs (19%); carbohydrate foods such as bread, pasta and cakes (18%); pre-cooked foods (buffet food) (15%).
Forty-six out of 94 (49%) of the vomit phobics compared to 0 out of 27 (0%) of the panic disorder group who responded reported that they had avoided having children because of a fear of vomiting. (We did not ask whether having children was avoided because of a fear of panicking) (Chi-square=21.32, df=1, p<.0001). Five out of 94 (5.3%) of the vomit phobics reported having terminated a pregnancy because of their fear of vomiting, and none of the 18 panic disorder group who responded had done so. Neither group had ever placed pressure on a partner to terminate a pregnancy due to a fear of vomiting (vomit phobics 0 out of 3) vs. panic disorder 0 out of 8. Vomit phobics were more likely to avoid general anaesthesia or surgery because of a fear of vomiting (vomit phobics 34% (32/93) vs. panic disorder 0% (0/28) (chi-square = 13.09, df = 1, p<.0001). (p. 145)

Quote 13: Using a 10-point rating scale (0 representing “not at all” to 10 being “very severe”), vomit phobic patients indicated the degree their fear of vomiting had interfered with their life. On average, their fear of vomiting had moderately impaired their work (mean 5.4, SD 3.6). Examples include taking days off work when they think someone in their office may be ill. Impairment in social life was rated as moderate (mean 6.7, SD 2.. An example would be avoiding social gatherings, parties and pubs where there was the risk of vomiting. Impairment was rated to a less extent in family life/domestic life (mean = 4.8, SD 3.4) This included avoiding contact with their children when they were ill and feeling guilty because they could not care for them. Handicap in intimate relationships was moderate (mean = 4.9, SD 3.4) but included terminating a pregnancy or sleeping in another room if their partner had been drinking. (p. 146)

Quote 14: The majority of the vomit phobics had sought help from their GP (70%) and had been referred to or sought help from a psychologist or psychiatrist (67%). Twenty-nine percent of the whole sample had received some form of therapy, which overall was rated as largely ineffective. Behaviour Therapy (BT) was mentioned by 20.3% of the vomit phobic patients in the study and was rated as least effective (mean = 1.71, SD 2.27). In comparison, cognitive behaviour therapy (CBT) was received by 17.9% of sample and was rated as moderately effective (mean= 5.23, SD 12.19). It was not, however, possible to establish the nature of BT or CBT. Medication (anti-depressants or anti-nausea drugs) was the most common therapy received (41.3%) and was rated as mildly effective (mean = 3.34, SD 2.58). Thirty-five percent of the whole sample had received hypnotherapy and also reported the effectiveness as mild. The psychopathology of vomit phobia 147 (mean = 2.07, SD 4.807). The percentages reported for the various treatments sought were based on the whole of the vomit phobia sample and not just the patients who sought therapy. (p. 146)

Quote 15: Vomit phobia is regarded as a simple phobia but this survey reveals a complex and chronic disorder. There was an overwhelming bias of women with vomit phobia (97%). The mean duration of the phobia was of 25.9 years, of whom many were significantly handicapped to the extent of some who were avoiding surgery or pregnancy because of their fear of vomiting. (p. 147)

Quote 16: One of the main findings is the overlap in the cognitive processes and behaviours with panic disorder (Clark, 1986). Vomit phobics frequently experience nausea in anticipation of vomiting as a symptom of anxiety. Furthermore, the selective attention and vigilance for vomiting is likely to intensify the sensations of nausea in a vicious circle. The sensation of nausea becomes misinterpreted as evidence of impending vomit and being paralyzed with fear. (We did not, however, enquire whether they interpreted other sensations of anxiety in the same or a different way). Vomiting is associated with the feared consequences of losing control, and to a lesser extent of becoming very ill or choking. These thoughts or images may become fused with reality. Beliefs about losing control or becoming ill are common in panic but the ratings of the probability and awfulness of the events were significantly higher in vomit phobics than the panic disorder group. Vomit phobics avoided situations that were associated with an increased risk of vomiting (e.g. pregnancy) or of others vomiting (e.g. being near a drunk). However, many of the situations avoided would be associated with an extremely low risk of vomiting (e.g. using a public toilet). In common with other anxiety disorders, safety seeking behaviours are likely to prevent individuals from disconfirming their fears of vomiting or intensifying the sensations. There were no significant differences in the activities avoided whether the vomit phobics were alone or accompanied by another person (which is different from individuals with panic disorder and agoraphobia who often use a partner or close relative to reduce the risk of panic attack occurring or to cope better in an attack). There is also significant overlap in the phenomenology with that of obsessive compulsive disorder (with fears of contamination) or of health anxiety. For some vomit phobics, there was an over-inflated sense of responsibility in the beliefs about the degree of influence in their ability to prevent themselves vomiting and in the checking of sell-by dates or the health of others or of washing their hands excessively. There were also surprisingly high ratings for beliefs about medical causes of nausea such as irritable bowel syndrome or migraine (rather than anxiety). There was no difference in the strength of conviction between the vomit phobia and panic disorder groups. This suggests that both groups have overlap with health anxiety to the same degree.
There is some overlap in vomit phobia with social anxiety. Most vomit phobics (77.6%) did not discriminate between their fear of vomiting in public or being alone. Only a minority had their main problems as being fear of negative evaluation and shame about vomiting in front of others. Overall, the concern that others will find them repulsive or will not want to know them if they vomit appears to be a secondary or additional concern for most vomit phobics.
Forty-one percent of vomit phobics feared themselves and others vomiting equally, and 47% feared mainly themselves vomiting and to a lesser extent in others. This suggests that the locus of fear in vomit phobia is predominantly internal. Only a small minority view others vomiting as the main threat. There may also be generalization of the fear in vomit phobics so that others vomiting may be a threat to themselves vomiting from contamination or because of the association and being reminded of their own fears. (p. 147)

Quote 17: Our study suggests a need to develop a detailed formulation and to identify the factors that are maintaining the beliefs and especially the safety seeking and avoidance behaviours. It is striking that for vomit phobics, despite a career of preventing themselves from vomiting, the frequency of vomiting is no less than the panic disorder group. Here the therapist might want the patient to conduct their own survey amongst friends or family to determine how frequently they have vomited during their lifetime in the absence of being drunk. Vomit phobics may, however, have a better recall of when they have been sick, which increases the frequency. Vomit phobics may recognize the low probability of the likelihood of vomiting but continue to believe that the awfulness of vomiting is too high or that the consequences of vomiting are too dangerous. They may hold an over-inflated responsibility about the degree of influence they have to prevent vomiting. As a result, their solution of avoidance, safety seeking behaviours and excessive vigilance for vomiting are now their problems. We would recommend a method of engagement similar to that of hypochondriasis (Clark et al., 1998) or obsessive compulsive disorder with a “vicious flower” of maintaining factors and to present a patient with two alternative hypotheses to test out. For example, “Theory A” is that the individual has a problem of vomiting and losing control. “Theory B” would be that the problem is of being worried about vomiting and losing control, rating vomiting as being 100% awful and therefore trying too hard to prevent themselves from vomiting. The therapist might discuss metaphors about their solutions (e.g. man in the hole) (Hayes, Strosahl and Wilson, 1999). The emphasis in engagement is focussing on the handicap and distress caused by the avoidance and safety seeking behaviours and excessive vigilance. Another strategy may be to help patients to question their over-inflated sense of responsibility, so that they can drop their safety seeking and avoidance behaviours and act “as if” the problem is worrying about vomiting rather than treating it as a problem of vomiting. Thus it is crucial to conduct behavioural experiments and enter situations and activities associated with nausea (caused by anticipatory anxiety) without excessive vigilance and safety seeking behaviours. The aim would be to refocus attention in avoided situations to disconfirm the prediction of vomiting and improve the quality of life caused by the handicap. Here the emphasis is on being functional and following valued directions in life, as the strategy of trying never to vomit has a significant cost and yet has no effect on the frequency of vomiting. (p. 148)

Reconceptualizing emetophobia: A cognitive–behavioural formulation and research agenda
(Boschen, 2007)

This paper explores the cognitive and behavioural factors that contribute to emetophobia and suggests some treatment options.

Quote 1: Fear of vomiting (emetophobia) is a poorly understood anxiety disorder, with little research published into its conceptualization or treatment. The current article uses established cognitive and behavioral models of other anxiety disorders as a basis from which to propose a detailed model of emetophobia. The model proposes that emetophobia results from a constellation of factors including a general anxiety-vulnerability factor, a tendency to somatize anxiety as gastrointestinal distress, a tendency to catastrophically misappraise nausea and other gastrointestinal symptoms, hypervigilance to gastrointestinal cues, beliefs about the unacceptability of vomiting, negatively reinforced avoidance behavior, and selective confirmation biases. (p.407)

Quote 2: This lack of knowledge of the nature of emetophobia is surprising given recently published data on the impact of the illness. In a sample of 56 emetophobics, Lipsitz et al. (2001) reported that emetophobia was associated with an early onset, chronic course (with a large subgroup reporting no periods of remission), and marked impairment for a large proportion of sufferers. Despite this, treatment–outcome studies are scarce (with no controlled outcome data), and there has been little specific examination of the cognitive factors involved in fear of vomiting, and consequently no incorporation of cognitive techniques into treatment packages specifically tailored to emetophobia. (p.408)

Quote 3: Once a person has acquired a specific phobia, cognitions can serve to maintain this fear. Thorpe and Salkovskis (1995) reported on the content of phobic individuals’ cognitions and their relationship to the phobia itself. Using a sample of 25 phobic individuals (including one with a phobia of vomit), the researchers used self-report instruments to assess the cognitions present in phobic patients when they are confronted with the feared object or situation. In this study, Thorpe and Salkovskis found that the frequency of ‘‘catastrophic cognitions’’ usually associated with panic disorder such as ‘‘I would go mad’’ was surprisingly high (32%). Interestingly, loss of control of excretory bodily functions was also investigated, with 8% signaling that this cognition was present. The authors also demonstrated that the intensity of phobic fear was related to their conviction in the accuracy of these cognitions, especially those related to harm and ability to cope. The conclusion drawn by the authors are that cognitive factors, especially those related to self-efficacy and harm from the phobic stimulus are important maintaining factors in specific phobia, similarly to other diagnoses like panic disorder. (p.411)

Quote 4: Individuals with emetophobia may show a heightened sense of sensitivity to the opinions of others around them, as is seen in social phobia. In individuals who hold beliefs that others will negatively evaluate them if they are sick, and that such negative evaluation is catastrophic, a risk of being sick becomes an extremely anxiety-provoking event. Most emetophobic individuals are more concerned about vomiting in the presence of others than doing so alone (Lipsitz et al., 2001). (p. 412)

Quote 5: Emetophobia also commonly presents with features that are more commonly attributed to Obsessive Compulsive Disorder (OCD). The obsessive preoccupation with their own gastrointestinal state resembles the bowel obsessions seen in some OCD cases. The recurrent checking (e.g., of whether food contains certain ingredients) and use of other rituals (e.g., in cooking) are hallmark symptoms of OCD that are sometimes observed in emetophobic individuals (Lipsitz et al., 2001). (p. 412)

Quote 6: Individuals who are vomit phobic have commonly had aversive experiences of themselves or others vomiting, and the onset of emetophobia may commonly follow medical illness (Lipsitz et al., 2001). Such situations may contribute to the hypervigilance to gastrointestinal cues, and may also act as components in an associative learning process. When such vulnerable people are placed under circumstances of increased stress, or other situations where gastrointestinal somatic symptoms may occur, their tendency to interpret ambiguous stimuli as threatening (Catastrophic misappraisal; see Table 1) leaves them ready to interpret such sensations as indicators of imminent danger. In emetophobia, the primary concern is that these interoceptive cues are indications that vomiting may be likely or imminent. (p. 412)

Quote 7: The perception that the person may be sick leads to a further increase in anxiety, and an associated escalation in gastrointestinal somatic symptoms. This escalation in symptoms then completes a positive feedback loop (see Fig. 1), where the increase in these interoceptive cues is appraised as further evidence that the individual may vomit. (p. 414)

Quote 8: the worry that results from the occurrence of a previous attack or associative learning experience, leaves the individual in a state of heightened sensitivity to the presence of interoceptive cues (Hypervigilance; see Table 1). This sensitivity acts to predispose the emetophobic individual to noticing any future occurrence of gastrointestinal symptoms. This sensitivity, coupled with the actual occurrence of such symptoms (and their everyday occurrence in normal digestion) is enough to elicit the catastrophic interpretation of these symptoms, bringing the individual back into the acute phase where they fear vomiting may occur. (p. 414)

Quote 9: In this component of the model, the concern over experiencing nausea attacks (or the actual experience of vomiting) leads the individual to avoid certain stimuli that they fear may place them at risk of experiencing future attacks. This may be manifest in avoidance of left-over food, pregnancy and associated morning sickness, sea travel or other similar experiences that may lead to sensations of nausea or gastrointestinal upset. This avoidance has several effects, as seen in other disorders. Firstly, the individual fails to habituate to the occurrence of gastrointestinal symptoms of anxiety, meaning that such cues are similarly likely to elicit anxiety in future. Secondly, the individual fails to gain from the learning in new experiences where mild nausea does not lead to subsequent vomiting (Selective confirmation; see Table 1). The individuals sense of self efficacy in the face of gastrointestinal symptoms is reduced, further strengthening avoidance behavior. (p. 414)

Quote 10: The conceptualization of emetophobia presented above highlights several potential targets for exposure-based interventions. (p. 415)

Quote 11: Modification of cognitions is a core component of successful treatments for panic (Barlow, Raffa, & Cohen, 2002; Clark et al., 1994), although there remains debate about whether or not this cognitive restructuring needs to be focused specifically on the catastrophic cognitions themselves (e.g., Brown, Beck, Newman, Beck, & Tran, 1997). Treatment for emetophobia based on the suggested model, would incorporate cognitive procedures such as training and assisting patients to identify, evaluate and modify problematic automatic thoughts. Specifically, cognitions that minor normal gastrointestinal stimuli are indicators of immediate vomiting would need to be addressed. (p. 416)

Quote 12: Distraction has fallen out of fashion after advances in the thought suppression literature since 1987 (Wegner, Schneider, Carter, & White, 1987; Wenzlaff & Wegner, 1987). There has also been considerable debate on the impact of distraction during exposure (e.g., Rodriguez & Craske, 1993). Despite this, it has formed a component of several successful cognitive behavioural treatment packages. While caution may be appropriate when considering the use of distraction techniques during exposure, such techniques may be useful to the patient in the short term if they find their attention drawn to gastrointestinal cues. (p. 416)

Quote 13: Arousal management skills such as applied relaxation training, are a mainstay of the cognitive behavioral treatment of anxiety disorders (Ost, 1987). In the model proposed here, emetophobic individuals are postulated as being particularly likely to experience anxiety as unpleasant gastrointestinal cues. If the individual can be taught to reduce their overall anxious arousal, then the occurrence of such distressing symptoms could also be lessened. (p. 416)

Cognitive-Behavioral Treatment of Emetophobia: The Role of Interoceptive Exposure
(Hunter & Antony, 2009)

This study basically looked at treating a case emetophobia in a woman in her early 40s with cognitive behavioural therapy, especially including the exposure to situations which provoked physiological symptoms that emetophobes normally interpret as indicative of imminent vomiting and showing them that these symptoms are merely anxiety symptoms.

Quote 1: Boschen (2007) reports that the functional overlap of emetophobia, panic disorder, OCD, and social anxiety disorder symptoms is not uncommon. For example, individuals with emetophobia may be fearful that others will evaluate them negatively if they are sick, and may therefore present with symptoms similar to social anxiety disorder. In addition, a preoccupation with gastrointestinal state and checking food ingredients may be observed in both emetophobia and OCD. Similarly, Craske (1991) remarks that the symptoms of panic attacks in specific phobia and panic disorder are often identical. (p. 86)

Quote 2: Margaret was informed that exposure would involve experiencing sensations associated with vomiting and situations that trigger her fear of vomiting, and not necessarily the experience of vomiting itself. Antony et al. (2006) have suggested that because fears of physical sensations experienced by individuals with emetophobia are similar to those reported by individuals with panic disorder, cognitive restructuring and interoceptive exposure techniques used in the treatment of panic disorder may be useful. Given the importance of panic attacks in Margaret’s emetophobic anxiety, and given that her panic symptoms were associated with predictions of an increased likelihood  of vomiting, both of these techniques were incorporated into Margaret’s treatment. After discussion with Margaret, it was agreed that the goal of therapy was to reduce Margaret’s fear of vomiting and her avoidance of situations associated with this fear. (p. 87)

Quote 3: 9 weeks of CBT emphasizing graduated exposure to feared situations and challenging anxiety provoking thoughts. Because many of Margaret’s fears of vomiting were triggered by internal sensations, including premenstrual symptoms, bloating after meals, temperature increases, and even anxiety- or panic-related symptoms such as increased heart rate, two additional strategies were also employed in her treatment: education about the origin and implications of physical symptoms of anxiety and the use of symptom-induction exercises. (p. 87)

Quote 4: In the fourth session, the role of thoughts in maintaining anxiety was discussed. In addition, a handout regarding the basis of physical symptoms of anxiety was provided to Margaret to read before the next session. The handout explained that physical symptoms of anxiety are natural and adaptive ways that the body responds to danger signals, and it emphasized that they are not dangerous in and of themselves. This session represented a turning point in therapy. Margaret returned to the next session quite discouraged. She had interpreted this information as meaning that much of the emotionally exhausting work she was doing to avoid or prevent vomiting over the course of many years may have been unnecessary. That is, she realized that many of her feared symptoms were simply her body’s response to fear—not a sign of impending vomiting. Despite Margaret’s discouragement, noticeable changes began to occur after this session in Margaret’s symptoms as well as in her affect and appearance. She made significant progress in confronting her symptoms (reducing her anxiety in several situations from severe to mild or none, as reported in Table 2), she seemed more cheerful and relaxed, and she began to wear brighter-colored clothing and makeup. (p. 88)

Quote 5: Interoceptive exposure (IE) exercises were also introduced to challenge feared symptoms, including symptoms of panic, and to help Margaret better understand that these symptoms are natural reactions of the body to particular stimuli. Margaret found that some of these exercises triggered symptoms similar to her panic attacks, and these became some of the most challenging exposure exercises she completed in therapy. Because the exercises triggered severe anxiety, she was encouraged to practice them regularly to develop a greater tolerance for these symptoms. (p. 88)

Fear of nausea and vomiting: the interaction among psychosocial stressors, development transitions, and adventitious reinforcement
(Klonoff, Knell, & Janata, 1984)

This paper explores the fear of nausea and vomiting in children and adolescents. It suggested that the problem was similar to school phobia or separation anxiety.
For all subjects in this study the fear began after a hospitalisation or illness which included nausea or vomiting.
Suggested that a combination of developmental transitions in the children’s lives (e.g. changing schools), stressors (e.g. parental divorce) and reinforcement of the symptoms (e.g. extra attention given to the child) may have helped to maintain their fears.

Quote 1: The positive attention received by at child during an illness may be experiences as even more reinforcing when contrasted with the lack of attention he or she perceives obtaining. This is particularly true when such perceptions are accurate given a major stressor or change in family situation which significantly changes the amount or quality of parental attention. (p. 266)
In the treatment parents were taught to ignore the child’s somatic and anxiety symptoms and focus on adaptive behaviours instead. Families had to follow a set of rules, including rules about eating meals and going to school. Children were also taught relaxation procedures. All children were symptom free at termination of the programme, and at follow up 6-18 months later.

Cognitive therapy for vomit phobia: a case report
(Kobori, 2011)

This paper describes the presentation and cognitive therapy treatment of a 30-year-old woman with emetophobia.

Quote 1: The client was a 30-year-old Japanese female who had been living in England for 10 years. She was working at a kindergarten as an assistant teacher. Although she had married an Englishman, all of her family members were living in Japan. The client vaguely remembered that she had suffered from vomit phobia since childhood (before the age of 10), but she could not recall exactly when and how it had developed. Despite such a long period, the phobia had not significantly impaired her life. Moreover, there was a period when she had been free from the phobia several years prior to therapy. However, the fear of vomit re-emerged when she developed panic disorder at the age of 28. The first episode of panic attack occurred when the client was unable to stop coughing while she was brushing her teeth. The manner in which she was coughing reminded her of the cough she had experienced when she was vomiting as a child. Physiologically, she started perspiring profusely, without any heat, and her arms and legs became numb. Following this episode, panic attacks frequently occurred, particularly when the client felt full or when she was in a crowd. She experienced the following symptoms: sweating, heavy stomach, feeling of sickness, numbness in limbs, fear, pounding heart, and difficulty in breathing. Because of this, she was unable to eat as she wanted (she lost 7 kg), unable to use public transport and her partner’s car, unable to go to restaurants and cafes, unable to eat in public and unable to go shopping. (p. 172)

Quote 2: She had previously undergone cognitive behavioural therapy (CBT) and had taken selective serotonin reuptake inhibitors for panic disorder and comorbid depression. Her depression improved through medication, while the panic disorder was partly improved by CBT; she was better able to use public transport for a short distance; she could eat out with a few close people; she felt more comfortable; and she was better able to go shopping. Despite the improvement in the panic disorder, her fear of vomiting had not significantly changed, and the following impairments were associated with her phobia. She was unable to relax when she ate and drank in public; she had neither consumed alcohol nor eaten meat for two years; she felt nervous at night for the fear of seeing someone who was inebriated; and she became nervous when she rode long distances by public transport. She also felt anxious when she took medication because of its possible side effects. (p. 173)

Quote 3: Situations that made the client anxious were first identified. She felt anxious when she felt sick, when she was feeling full after eating and when she was near someone who was inebriated. She was hyper-vigilant about her surroundings and became anxious when she heard that somebody had vomited, when she watched news stories about epidemics, and when she saw someone who was bent over and looking downward as if he/she were sick. In the above situations, she had made a variety of efforts to prevent herself from vomiting and to avoid seeing others vomiting. Her behaviours included avoiding pubs on weekend nights, washing and gargling carefully when she was unwell, avoiding meat and alcohol, eating less so that she did not feel full, drinking mint tea when she thought she had eaten a lot, taking contraceptives and avoiding medication.
The case formulation was collaboratively developed based on the client’s past experiences. Typically, triggers such as drinking alcohol and eating meat led to bodily changes such as hot flashes and stomach discomfort. These sensations made her pay more attention to the inner workings of her body and made her think ‘I’m going to be nauseous’ and ‘My stomach is going to feel heavy’. These thoughts made her anxious, and the anxiety reinforced the bodily changes. As this vicious circle continued, she actually felt nauseous and her stomach became heavy. She then became convinced that she was going to vomit, which intensified her anxiety (Figure 1). Finally, after the circle repeated itself over and over again, the triggers began to elicit safety-seeking behaviours and avoidance. For example, she had to drink mint tea when she thought she had eaten a lot, she had not consumed meat and alcohol for more than two years, and she had tried to avoid situations where she had to drink alcohol or eat meat. Throughout the sessions, her underling beliefs were discussed and elaborated upon, such as ‘I’m more likely than others to vomit when I’m full, when I eat meat, when I drink, or when I have a fever’. (p. 173)

Quote 4: The behavioural experiments were organized in order to break down the vicious circle by terminating the avoidance and dropping safety-seeking behaviours. The client and therapist first compared her belief and a less-threatening, alternative belief. Her belief was, for instance, that she would vomit if she drank alcohol. Evidence to support this was that she had felt sick when she had drunk alcohol in the past. The alternative belief was that she was extremely worried that she would vomit when she drank alcohol, and she engaged in counter-productive behaviours that would maintain her belief. Evidence to support this was that, in retrospect, she had never vomited when she drank; rather, she may have been more likely to become sick because she paid more attention to her body than usual and became anxious by catastrophizing about the sensations.
In order to demonstrate this, attention training was introduced so that she could understand how increased self-focused attention affected her bodily sensations and subsequent thoughts and moods. After practising how to shift her attention, she was asked to intake a small amount of alcohol and pay attention to internal cues such as how her face, throat and stomach felt. Next, she was asked to pay attention to external perceptions and shift her attention from one perception to another. The client soon understood that self-focused attention intensified her anxiety and bodily sensations.
When the client was asked what would happen if she drank alcohol, she predicted that she would feel sick. However, once she started drinking while shifting her attention, she began to enjoy drinking. After the experiment, she learned that she was capable of consuming alcohol without vomiting, although it was a very surprising experience. She also wondered whether she would be able to drink alcohol in a group. This concern was explored, and the next behavioural experiment was set up to address this issue. Similarly, another series of behavioural experiments was organized to test her belief that she would feel full and eventually vomit if she ate meat and so on. During the later stages of the therapy, she planned and carried out a behavioural experiment to test what would happen when she went to avoided places, including a pub. Although she saw inebriated people, she did not witness anyone vomiting. (p. 174)
The client was required to probe her friends’ beliefs about various vomit related scenarios, to show her that her own beliefs were often untrue or substantially distorted.

Quote 5: The client asked five of her friends to complete a simple questionnaire that included the following questions: ‘When do you vomit?’; ‘How severe would a fever have to be to make you vomit?’; ‘How many times have you seen someone vomiting at/near pubs?’; and ‘How many times have you been to pubs in your lifetime?’ The results suggested that people do not usually vomit because of a fever, when they eat a lot, when they eat meat or when they drink alcohol responsibly. She was surprised by the proportion of the number of responses about seeing others vomiting to the number of responses about going to pubs (2.5% on an average). (p. 175)
Changes in the client’s safety seeking and avoidance behaviour as well as her anxiety and depression scores were assessed throughout the treatment.

Quote 6: Since there were no outcome measures determined for vomit phobia, the client was asked to evaluate her (1) preoccupation and (2) safety-seeking behaviour (SSB) on a scale of 0 (never) to 100 (at all times). Preoccupation was rated by asking: ‘Over the past week, how much time did you spend thinking about vomiting, your health, eating, alcohol, and transportation?’ Similarly, her SSB was rated by asking: ‘Over the past week, how much effort have you made to avoid vomiting, avoid others who were vomiting, stay healthy, avoid alcohol, and stay home at night?’ These rating ratings gradually decreased from 75 for both preoccupation and SSB at session one to 30 for preoccupation and 20 for SSB at session seven (Figure 2). These gains were maintained throughout the follow-up sessions with preoccupation being 35 and SSB being 12 at the six-month follow-up.
Over a period of seven sessions, the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) score decreased from 15 to 6, and the Beck Depression Inventory (BDI; Beck,Ward,Mendelson,&Erbaugh, 1961) score decreased from 8 to 3. These scores remained low at the 6-month follow-up session, with the BAI score being 1 and the BDI score being 3 (Figure 3). (p. 175)

Quote 7: Although the treatment strategies were selected on the basis of the case formulation (Boschen & Oei, 2008), they incorporated the techniques proposed by the cognitive models of vomit phobia (Boschen, 2007; Veale, 2009). Attention training was introduced so that the client could understand how increased self-focused attention to her body affected her bodily sensations and subsequent thoughts and moods. The present study employed behavioural experiments with the aim of disconfirming the client’s beliefs by approaching avoided situations and dropping safety-seeking behaviours. These experiments modified her beliefs such as ‘I’m more likely than others to vomit when I’m full, when I eat meat, when I drink, or when I have a fever’. As she learned that she was able to drink alcohol and eat meat without vomiting, her social life became more enjoyable. This subsequently increased her motivation to participate in the experiments. As recommended by Veale and Lambrou (2006), the client conducted an opinion survey of her friends. The survey consolidated the belief changes described above and served to modify the remaining beliefs such as ‘I’ll vomit when I have a fever’ and ‘I’ll see a lot of drunk people at the pub’. (p. 176)

Cognitive behaviour therapy for a specific phobia of vomiting
(Veale, 2009)

This paper discusses the features and treatment of a SPOV.
In the paper it gives the DSM-IV criteria for SPOV, which may be useful:

Quote 1:
(a) Marked and persistent fear of vomiting that is excessive or unreasonable, cued by the presence of vomit or anticipation of vomiting.
(b) Exposure to cues related to vomiting almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally pre-disposed panic attack.
(c) The person recognizes that the fear of vomiting is excessive or unreasonable.
(d) Phobic situations related to vomiting are avoided or else endured with intense anxiety or distress.
(e) The avoidance, anxious anticipation, or distress interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
It discusses the ways in which emetophobes evaluate vomiting and respond to a potential threat of vomiting.

Quote 2: There are various responses to a current threat of impending vomit.
(a) Experiential avoidance of thoughts and images of oneself or others vomiting and interoceptive cues for nausea.
(b) Avoidance of external threats that could lead to vomiting or nausea.
(c) Hyper-vigilance for monitoring external threats (e.g. people who could be ill or an escape route).
(d) Self-focused attention for monitoring of nausea.
(e) Worry, self-reassurance and mental planning of escape routes from others vomiting.
(f) An over-inflated sense of responsibility and belief in one’s ability to stop oneself from vomiting.
(g) Safety-seeking behaviours including compulsive checking and reassurance seeking.

Quote 3: In a functional analysis, all these responses will have an unintended consequence of increasing the frequency of thoughts about vomiting and symptoms of nausea and will prevent disconfirmation of the threat of vomiting. Avoidance of people and activities related to vomiting prevents extinction and prevents disconfirmation of expectations and the ‘awfulness’ of a fear and reinforces avoidance of nausea and cues related to vomiting. Vomiting may occur rarely but it does not lead to a diminished fear response, perhaps because it does not occur frequently enough and the association with fear is very powerful. (p. 276)

Quote 4: Most people with a SPOV evaluate vomiting as being 100% awful and if given the choice would prefer to die rather than to vomit. The therapist should try to explore the awfulness of vomiting but be aware that people with SPOV are usually unable to articulate why vomiting is so awful other than knowing they have to avoid it all costs. (p. 277)

Quote 5: The most common cognitive process in SPOV is of worry and mentally planning how to prevent oneself from being sick or how to cope with someone else being sick or a related cue. The therapist should try to identify the client’s positive beliefs for worrying (e.g. ‘If I worry I can mentally prepare myself for vomiting’, or ‘If I worry I can then prevent vomiting from happening’) and the unintended consequences of the worry. (p. 277)

Quote 6: Avoidance can usually be divided into external or internal triggers and the former a trigger for the latter. External triggers include:
(a) Adults or children who could either be ill (and are therefore viewed as contagious) or who may be at risk of vomiting (e.g. drunks). The avoidance might extend to restricting the activities of any children who may be in contact with other children at school or at a party.
(b) Avoidance of situations or activities such as going on holiday abroad, places where the client might see drunks, visiting people who might be ill, travelling by boat, travel by aeroplane, drinking alcohol in normal amounts, being in crowded places, using public transport, pregnancy, fairground rides, using public toilets or door handles, medication, going to the dentist, anaesthesia or becoming pregnant.
(c) Avoidance of food. Food restriction may occur in a variety of ways:
• Restricting the amount of food eaten that reaches one’s stomach, thus reducing the amount that might be vomited. Alternatively a restricted amount is equated with feeling ‘full’, as eating more than this could lead to vomiting.
• Restricting food in certain contexts (e.g. not eating food cooked by someone else or in an unfamiliar restaurant).
• Restricting certain types of food. Certain foods (e.g. shellfish, poultry curries, dairy products and fried fast food) might have a slightly higher risk for vomiting. Alternatively certain foods may have become associated with a past experience of vomiting which have now led to avoidance. Others will only eat a narrow range of idiosyncratic foods which are regarded as safe. An example is a woman who restricted her food to chocolate, crisps and Coke which had to be bought from a specific supermarket. Restricting food may lead to becoming underweight, which may have a number of physiological consequences which are often reinforcing – for example emotional numbness which may reduce anxiety. For others disordered eating may be a further factor in increasing nausea.
Avoidance may also be internal and include:
(a) Experiential avoidance of thoughts or images relating to vomiting. People with SPOV may not want to even accept their vulnerability to vomiting and are likely to fuse their thoughts of vomiting with past associations so they are ‘felt’ to be in the present. Euphemisms such as ‘being ill’ or ‘unwell’ may be used by clients when discussing vomiting. Avoidance may be described as distraction, suppression or some other behaviour that has the function of preventing thinking about vomiting.
(b) Experiential avoidance of nausea and gastrointestinal symptoms. These might include ‘feeling bloated’ leading to restriction of the amount of drink or food eaten. (p. 278)
Safety-seeking behaviours are performed as a response when a client is unable to escape or as a means of controlling the anticipation of being sick. These behaviours may be either an overt behaviour or a covert mental act performed to prevent oneself or others being sick. Overt behaviours include compulsive checking of ‘sell by’ dates and freshness of food, reassurance seeking, 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 the thirteenth stair’ or repeating a word or action a certain number of times to prevent herself from vomiting. Membership of an internet support group may be a safety-seeking behaviour. Initially membership may be very supportive especially regarding communicating with others with the same fears. However, membership may also raise anxiety with frequent virus alerts and constant seeking of reassurance from one another by phone, texts or via a bulletin board.
People with SPOV frequently drink bottled water or a sugary fizzy drink, which they carry around with them. This may be a form of threat monitoring (e.g. ‘If water’s going down, then nothing can come up’) or a prevention of vomiting (e.g. ‘It can stop me from vomiting’). However, it has the consequences of increasing preoccupation, diminishing appetite, and perhaps causing nausea and weight loss.
Covert acts include the client mentally reviewing her actions and reassuring herself that she will not be sick. Various safety-seeking behaviours are also performed in order to prevent impending vomit. People with SPOV attempt mentally to control the reflex act of vomiting. They may take anti-nausea medication or suck antacids, ice or mints. These behaviours are reinforcing because they appear to work but have the unintended consequence of increasing self-focused attention and preoccupation with vomiting and prevent disconfirmation that vomiting will not occur. (p. 278)
The paper also explores some ways in which therapists can help those with a SPOV, using cognitive behavioural techniques.

Quote 7: The therapist should normalize the experience of vomiting as being an adaptive process that increases the client’s chances of survival if she became ill. Information may be given about how vomiting is beneficial and prevents disease by getting rid of toxins. Thus the rat is the only animal that cannot vomit and one reason why rat poison is so effective. (p. 279)

Quote 8: A client with SPOV is often reluctant to engage in any treatment that involves exposure to any risk of vomiting. (p. 280)
It suggests that it is useful to help clients to understand how they are maintaining their fears.

Quote 9: Not having control over a reflex act is a difficult concept for many people with SPOV who believe that if they are going to vomit they can prevent it from happening. This is an over-inflated sense of responsibility similar to that found in OCD and generalized anxiety disorder (GAD). Clients may believe that their safety-seeking behaviours have prevented them from vomiting in the past and are often proud of the number of years since they last vomited. (p. 281)

Quote 10: People with a SPOV may recognize the low probability of the likelihood of vomiting but continue to believe that the awfulness of vomiting is too great and do everything they believe necessary to stop themselves from vomiting (or even thinking about it). In this respect it has similarities with an over-inflated sense of responsibility and the need for certainty as in OCD (Salkovskis et al. 2000). Many clients say that they would prefer to be in control and die rather than vomit. For this reason it may be more helpful to focus the individual on what she really wants her life to represent – rather than being someone whose life is dedicated to not vomiting or to following the values that were identified in her assessment. A person with SPOV is being asked to act as if they do not have a SPOV even if they believe that vomiting is awful or life threatening. This has many implications in trying to give up control over vomiting and accepting the uncertainty that vomiting may occur. It is helpful to explore the meaning or imagery associated with ‘losing control’ (e.g. the idea of not being able to prevent oneself from vomiting and the vomiting persisting). A major step for the client is accepting that if her body needs to vomit (e.g. food poisoning) then there is very little control in preventing vomiting (and it would be dangerous if one could inhibit removal of toxins). One can partly demonstrate magical thinking by a behavioural experiment in which the client is encouraged to wish herself vomiting when she feels nauseous or bloated. It is also possible to demonstrate the lack of control over intrusive thoughts and images of vomiting by standard thought control experiments (e.g. try not to think of a ‘pink elephant’). The message is that trying to control thoughts or feelings of vomiting is the problem that increases distress and not the solution.
For the client, the fear of losing control is related to the need for certainty that she is not going to vomit. As in OCD, this is questioned by pragmatism. There is no guarantee that whatever a person with SPOV does in therapy to overcome her fears will not be associated with vomiting (or it may occur by coincidence for another reason). However, the cost of failure to overcome her fear and trying to prevent herself from vomiting is the guarantee that she will be disturbed by a SPOV for the rest of her life and be unable to follow her valued directions in life. (p. 282)
The paper discusses exposure therapy and suggests that gradual exposure to feared vomit related situations can be very helpful.

Quote 11: In most people with SPOV, the phobia is of themselves vomiting not of vomit. However, for exposure, it is impractical and unethical to induce repeated vomiting by the use of emetics or to self-induce vomiting. Indeed it could make a client even more determined never to vomit again and repeated vomiting could theoretically lead to electrolyte imbalances or dental damage. (p. 284)

Quote 12: Some clients report that watching simulated or real vomiting by others may not be sufficiently realistic and does not reduce rating the ‘awfulness’ of themselves vomiting. Special attention should be made whether the client is using neutralizing, self-reassurance or other safety behaviours believing that she can prevent herself from vomiting. Exposure can also be done to internal sensations that are cues to vomiting (Hunter & Antony, 2009). They include cues such as drinking a full can of a fizzy drink in one sitting and eating more at mealtimes to induce a sensation of bloatedness; holding mouthwash in mouth for 30 seconds and reading in a moving vehicle to induce a sensation of nausea. (p. 285)

Quote 13: If the client has identified intrusive imagery and aversive memories of vomiting as a child then the therapist may need to add exposure in imagination or as imagery re-scripting. The procedure is derived from Arntz &Weertman (1999) and Smucker & Dancu (1999). It has not yet been evaluated in SPOV but the procedure has been successfully used in social phobia (Wild et al. 2008) and other anxiety disorders. Clients are asked to describe their aversive memory in three stages. The first stage involves re-living the aversive memories from the age when they first experienced vomiting. This consists of exposure in imagination and should be described in the first person, present tense and from a field perspective in as much detail as possible. The client should first state their age and the context. Recounting the memory should be done in slow motion like a video frame-by-frame account. Ensure that there are no ‘hot spots’ that are being avoided and if necessary ask the client to describe in more detail those aspects which are more anxiety provoking. She should describe the sensations of the vomiting as well as the colour, taste and texture of the vomit. Ask the child to describe the meaning of the experience and what the child needs or would like to happen next. This allows the meaning of the event to be updated in the next phase of repeating the memory from an adult’s self-perspective. (For further details of imagery re-scripting see the above references.) A variation on imagery re-scripting is ‘Competence Imagery’. This is described by Moran & O’Brien (2005) in a girl who avoided social environments because she feared encountering vomit or others vomiting (and was not therefore typical of people with SPOV). Therapy included systematically pairing anxiety-provoking conditioned stimuli (video scenes of someone vomiting) with competence images. The client chose to imagine playing her musical instruments, swimming lengths in the pool, or practising yoga postures, which were actions she believed she could perform well. Theoretically this could be used in others with SPOV with exposure to cues associated with vomiting. (p. 285)

Quote 14: Safety-seeking behaviours will interfere in exposure and are the main obstacle to progress. The goal is to drop all the responses that are believed to maintain the fear. This includes cognitive processes such as worry and attentional biases towards potential risks. If you identified the meta-cognitions about the cognitive processes (e.g. ‘It can help me mentally prepare myself for vomiting’), then these can usually be challenged pragmatically on the basis of their unintended consequences and their costs (e.g. ‘How effective is worry at mentally preparing yourself? Is this something you would teach others? If not, why not?; What is the cost of mental planning?’).
Dropping of safety-seeking behaviours and self-focused attention may be assisted by behavioural experiments in which the behaviour is either increased or decreased and asking the client to make specific predictions. Does the use of a safety-seeking behaviour or compulsion increase or decrease her worry and distress about vomiting? Does focusing her attention internally and monitoring the level of nausea increase distress compared to focusing externally? A similar approach can be used for compulsions. Some clients excessively check the freshness of food, have abnormal hygiene measures, check excessively health of themselves and others, follow superstitious behaviours, repeatedly seek reassurance, perform excessive cleaning of kitchen area and toilet. Compulsions are identified and can be added to the hierarchy for them to be discontinued. Similar to people with OCD, it is usually important to identify the termination criteria for a compulsion (e.g. feeling comfortable) that are problematic in maintaining the behaviour and to ensure that if a compulsion is conducted, then the patient ‘undoes’ it by re-exposing herself to the original risk. (p. 286)

Clinical Features, Prevalence and Psychiatric Complaints in Subjects with Fear of Vomiting
(Hout & Bouman, 2011)

This study explores some of characteristics of emetophobia and explores its prevalence in a Dutch sample.

Quote 1: Fear of vomiting was surprisingly common in the Dutch community sample. The point prevalence rate of fear of vomiting was 8.8%. The proportion of women in this group was four times higher than the proportion of men. (p. 533)

Quote 2: Overall, the majority of the vomit‐fearful participants (76.8%) reported to fear vomiting themselves, whereas 40.3% of the participants were afraid to vomit in the presence of other people, and 45% feared to see others vomiting. About a fifth (21.2%) feared a combination of all three vomiting related situations. (p. 533)

Quote 3: In general, the rates for (additional) psychiatric complaints among the vomit‐fearful Internet participants were significantly higher than in both community groups. Self‐reported complaints referring to panic disorder, agoraphobia and social phobia were substantially more prevalent among the vomit‐fearful Internet participants. Interestingly, also in the control group without fear of vomiting, psychiatric complaints were reported. There was an unexpected high prevalence (12.2%) of self‐reported social phobic complaints. The total number of self‐reported complaints referring to psychiatric disorders differed significantly between the three groups (F(2,56) = 7.38, p = 0.001; control community group: M= 1.6, SD = 1.2; vomit‐fearful community group: M= 2.7, SD = 1.4; vomit‐fearful Internet group: M= 2.9, SD = 1.3). Both vomit‐fearful groups did not differ from each other on the total number of disorders but showed significantly higher mean figures than the control group without fear of vomiting (p < 0.001). (p. 535)

Quote 4: all (100%) of the vomit‐fearful Internet participants reported nausea or gastric complaints when anxious compared with 46.7% of the vomit-fearful community participants and 29.7% of the control community group. Over 60% of the vomit‐fearful Internet participants perceived a variety of panic symptoms: palpitations perspiration, trembling, feeling of suffocation, chest pain or pressure, dizziness and faintness, derealization, hot and cold flushes, fear of losing control or getting mad. (p. 535)

Quote 5: Panic attacks (i.e., at least four panic symptoms, either related or unrelated to fear of vomiting) were experienced by 57.9% of the vomit‐fearful Internet participants, 33.3% of the vomit‐fearful community participants and 6.4% of the participants without fear of vomiting (Fisher’s Exact Test, p < 0.0001). (p. 536)

Quote 6: The vomit‐fearful Internet and community participants in this study had no formally established DSM diagnosis; still, they reported high levels of subjective fear and avoidance, a variety of panic symptoms when anxious, and developed elaborated avoidance strategies. These strategies included a vast variety of active and passive avoidance behaviours such as continuously checking the expiration date of food products and avoiding people who are sick—especially those affected with stomach flu—or drunk. The results of this study suggest that fear of vomiting is a chronic and disabling condition that may cause significant impairment in daily functioning. Severity indices of complaints found in our vomit‐fearful samples are largely in line with the findings of Lipsitz et al. (2001) and of Veale and Lambrou (2006) on vomit‐fearful subjects. The vomit‐fearful Internet subjects who participated in our study can be considered more seriously impaired than the vomit‐fearful participants from the community sample, reporting more avoidance and safety behaviours and more panic symptoms. They mentioned gastric complaints when anxious and feared nausea and vomiting. Almost 90% of the vomit‐fearful Internet group had been treated for fear of vomiting in the past, and more than half of the respondents still received treatment for their complaints.
Despite the fact that the main feared consequence of the vomit‐fearful participants was to become nauseous and consequently to vomit, it appeared that they had very limited experience with vomiting themselves. The utilized avoidance behaviour seemed very successful in the prevention of vomiting as the fearful participants reported that years had passed since their last vomit experience. Interestingly, also some subjects in the control community group without fear of vomiting reported avoidance of potential vomiting situations but significantly less than the vomit‐fearful Internet participants (see also Table 2). One might postulate that although vomiting is not very likely to occur in daily life, it has such potentially threatening capacities (e.g., related to disgust, illness and loss of control) that even subjects without fear of vomiting engage in some sort of avoidance to diminish the risk of vomiting.
Although, the main locus of the fear may vary between vomit‐fearful patients, results show that there is a high degree of overlap between the loci. About a fifth of the vomit‐fearful subjects reported fear of vomiting themselves, and of vomiting in the presence of others, and to see other people vomiting. (p. 536)

Quote 7: Only two studies (Philips, 1985; Becker et al., 2007) reported prevalence estimates for fear of vomiting. Philips (1985) found prevalence figures of 3.1% for men and in 6% for women in the USA. Findings from the Dresden Mental Health Study found a lifetime prevalence rate of 0.2% and a point prevalence of only 0.1% in female participants. In our random Dutch community sample, fear of vomiting was present in 1.8% of the men and in 7% of the women. The point prevalence rate for the total sample was found to be even higher (8.8%) than the 1‐month prevalence rate (5.5%) for specific phobia in the Netherlands (Bijl et al., 1998). These findings show that self‐reported fear of vomiting is a frequent occurrence in the Dutch community. (p. 537)

Quote 8: Cognitive processes such as selective attention for internal sensations and hypervigilance for seeing others vomiting play an important role in the maintenance of vomiting fears. Based on our clinical experiences with (sub)clinical subjects and research on fear of vomiting so far, these processes are expressed in the three loci (fear to vomit themselves, fear that other people vomit in their presence and fear to vomit themselves in the presence of other people) in several ways. The fear to vomit themselves can be expressed by some subjects through fear and avoidance of direct confrontation with emetophobic stimuli like, for instance, unknown (e.g., exotic) or perishable food, because they fear to become sick and to vomit as a consequence. Other subjects are afraid to vomit because of a condition that produces nausea like pregnancy, car sickness or anxiety/panic. The fear that other people vomit in their presence can be expressed through two more indirect pathways. Some subjects fear vomiting through confrontation with people with a contagious gastroenteritis, whereas others fear to vomit as a reflex to confrontation with people perceived as having a greater risk of vomiting (e.g., drunk or sick people). The fears of vomit fearful subjects that are afraid that other people see them vomiting contain a clear social component (i.e., shame, embarrassment). (p. 538)

An internet-based study on the relation between disgust sensitivity and emetophobia
(Van Overveld, De Jong, Peters, Van Hout, & Bouman, 2008)

This study explored whether disgust propensity (how quickly the individual experiences disgust) and disgust sensitivity (how negatively the individual evaluate this disgust experience) are related to emetophobia.

Quote 1: As vomit itself is one of the few universally accepted disgust stimuli (Rozin, Haidt, & McCauley, 2000), it seems reasonable to suspect that disgust and fear of contamination are somehow involved in emetophobia. Disgust may be involved in the etiology and maintenance of psychopathology in various ways. First, it has been argued that certain stimuli are characterized by high levels of contamination potency. Objects that are regarded highly disgusting, and that are capable of engaging physical contact with the individual, tend to be evaluated as having high contamination potency. For example, spider phobics consider spiders to be highly disgusting objects with a high contamination potency (Mulkens, de Jong, & Merckelbach, 1996; Thorpe & Salkovskis, 1998). Consequently, research indicated that indeed spider phobia may be better understood as a fear of physical contact and contamination with a disgusting object (de Jong & Muris, 2002).
A second pathway in which disgust may be involved in psychopathology may be that some people are extremely sensitive to the experience of disgust and contamination. Recent work showed that for the development of psychopathology, it may not only be relevant how often people experience disgust (disgust propensity), but also whether they evaluate this experience negatively (i.e., disgust sensitivity; van Overveld, de Jong, Peters, Cavanagh, & Davey, 2006). Recent reports indeed suggest that emetophobic individuals tend to avoid being disgusted, mostly in an attempt to avoid related feelings of nausea (Boschen, 2007; Lipsitz et al., 2001; Veale & Lambrou, 2006).
The primary aim of the present study was to determine whether individuals with emetophobia display elevated levels of both disgust propensity and disgust sensitivity. (p. 525)
This study found that emetophobes displayed elevated disgust propensity and disgust sensitivity. Disgust sensitivity in particular was a strong predictor of variance in scores on an emetophobia scale.

Quote 2: The main findings can be summarized as follows: (a) the emetophobic group demonstrated elevated levels of both disgust propensity and disgust sensitivity, compared to the control group, (b) there was a strong interrelationship between the intensity of emetophobic complaints on the one hand and the levels of disgust propensity and disgust sensitivity on the other, (c) most important, disgust sensitivity proved consistently to be the single best predictor of the variance in scores on the EQ. (p. 528)

Quote 3: The present findings confirm the view that disgust sensitivity appears involved in disgust-relevant complaints. Most importantly, upon studying the relation between disgust sensitivity, disgust propensity and the Emetophobia Questionnaire, disgust sensitivity proved the single best predictor of the variance in scores on the EQ. Thus, from the data from the present research, it can be concluded that disgust sensitivity contributes more strongly than disgust propensity to emetophobia. This strengthens the previous postulation that the differential role of disgust propensity and disgust sensitivity may vary across disorders (van Overveld et al., 2006). (p. 529)

Quote 4: Third, in line with earlier studies, the gender distribution of emetophobic complaints was extremely skewed. Previously, an internet survey by Lipsitz et al. (2001) revealed that 89% of the emetophobic individuals were women, Veale and Lambrou (2006) found 97% of the emetophobic sample in his study to be women. Emetophobia appears to be found predominantly in young women who are relatively high educated. One explanation for this could be that disgust propensity is crucially involved. Research indicates that women are characterized by elevated levels of disgust propensity (Matchett & Davey, 1991;Ware, Jain, Burgess,& Davey, 1994), and that this may explain why disgust-relevant psychopathology is observed predominantly in women (Olatunji, Arrindell, & Lohr, 2005; Olatunji, Sawchuk, Arrindell, & Lohr, 2005). Even so, compared to contamination-related OCD, or other disgust-relevant disorders, e.g., blood phobia, the gender distribution of emetophobia appears extremely skewed. (p. 530)

Abnormal Eating Behaviour in People with a Specific Phobia of Vomiting (Emetophobia)
(Veale, Costa, Murphy, & Ellison, 2012)

This paper gives some useful insights into the way in which many emetophobes restrict their eating in order to prevent vomiting. The study recruited 94 participants with SPOV. They were divided into those who reported restricting their food (SPOV-R) (n = 32) because of fear of vomiting and those who did not restrict their food (SPOV-NR) (n = 62). The study found that those who reported restricting their food had greater impairment and symptoms than those who did not.

Quote 1: A specific phobia of vomiting (SPOV) is a chronic disorder that is more prevalent among women (Lipsitz, Fyer, Paterniti, & Klein, 2001; Veale & Lambrou, 2006). It is popularly known as ‘emetophobia’. Individuals with SPOV are often significantly handicapped (e.g., avoiding a desired pregnancy or a required operation with an anaesthetic). People with SPOV may be assessed and treated in eating disorder units. Manassis and Kalman (1990) reported on four adolescent girls with SPOV who were underweight and misdiagnosed as having anorexia nervosa. In all four cases, refusal to eat resulted from fear of vomiting and not from a desire to lose weight. Vandereycken (2011) recently conducted a survey of eating disorder specialists, and SPOV was reported as unknown to 29.7% of respondents; 48.5% said that they observed it in their own practice, 68.5% agreed that it was a disorder in its own right, and 61.3% thought it was worthy of more attention.
Clinical observation suggests that the behaviour of a person with SPOV is consistent with trying to eliminate all risks of vomiting (or at least the amount that is vomited or cues that remind the person of vomiting). One way to do this is to restrict one’s food in one of the following patterns (Veale, 2009).
1. Restricting the amount of food eaten, and thus, in the mind of the person with SPOV, reducing the amount of food that might be vomited. Alternatively, a restricted amount is equated with feeling ‘full’, as eating more increases the risk of vomiting.
2. Restricting food in certain contexts (e.g., avoiding eating food cooked by someone else or in a salad bar, buffet, or restaurant) as this decreases control over food preparation and increases the perceived risk of vomiting.
3. Restricting types of food. Certain foods (e.g., seafood) might have a higher risk for vomiting. Alternatively, foods associated with past experiences of vomiting are now avoided because of a learnt association. A variation of this is restriction to a narrow range of idiosyncratic foods that are regarded as ‘safe’ as they are not associated with vomiting. This is akin to ‘magical thinking’. An example is a woman who restricted her food to chocolate, crisps, and Coke, which had to be bought from a specific supermarket location. (p. 414)

Quote 2: The proportion of participants with a BMI <18.5 was 23.1% in the SPOV-R group and 1.8% in the SPOV-NR group. Differences between the two groups in the proportion of underweight people were statistically significant. The SPOV-R group reported symptoms of nausea significantly more often than the SPOV-NR group (Table 1). The SPOVR group had significantly higher scores on the SPOVI, OCI, HAI, GAD-7, and WSAS questionnaires, compared with the SPOV-NR group. This reflects greater severity of anxiety symptoms and impairment. Both groups scored in the clinical range of the HAI, indicating elevated levels of health anxiety. In comparison with the SPOV-NR group, the SPOV-R group reported greater interference in their life (in particular, in relationships, work, social life, leisure activities, and home management) due to their SPOV. There were no significant differences between the two groups in the severity of disgust sensitivity or depression. (p. 416)

Quote 3: The SPOV-R group had significantly higher avoidance rates for eating at restaurants, salad bars or buffets, or food not prepared by themselves (Table 1), compared with the SPOV-NR group. The SPOV-R group was also more likely to avoid foreign meals and precooked foods than the SPOV-NR group; statistical significance was not reached for the other food groups (Table 2). (p. 417)

Quote 4: The SPOV group as a whole reported engaging in behaviours aimed at reducing the risk of vomiting, in particular, excessively smelling or checking sell by dates or freshness of food (82.8%) and cooking food for longer than others consider necessary (62.4%). However, a lower percentage was found to be using rituals to prevent themselves from vomiting (28.3%). The SPOV-R group was significantly more likely to report cooking food for a longer period than others consider necessary, compared with the SPOV-NR group; the difference for the other behaviours was not significant. (p. 417)

Quote 5: This study included a relatively large sample of people with SPOV who had either sought help at our clinic or were part of Internet support groups. The results showed that restricting food ‘often’ or ‘always’ and abnormal eating behaviour occur in about one third of people with SPOV. Across the whole SPOV group, 8.5% were underweight, with a BMI of less than 18.5. This prevalence is higher than the estimated 1.6% underweight adults found in a normal adult population (Fryar & Ogden, 2010). When SPOV is accompanied by food restriction, then there is an associated significant increase in the severity of the symptoms of SPOV: obsessive compulsive disorder, health anxiety, general anxiety, and overall impairment.
The relationship between food restriction and weight loss with increased severity of SPOV symptoms is likely to be bidirectional, with one aggravating the other. For example, food restriction was associated with increased symptoms of nausea, which may be misinterpreted as evidence of increased risk of vomiting and further restriction of food. (p. 417)

Brief Treatment of a Vomiting Phobia
(Ritow, 1979)

This paper discusses the treatment of a 21-year-old with emetophobia. The treatment involved motivating the woman to vomit (exposure). The paper contains a potentially useful description of a typical person with emetophobia.

Quote 1: A married, 21-year-old female Caucasian majoring in art history requested treatment for a vomiting phobia. At age nine she was ill and vomited once, and two weeks later she faked an appendicitis attack to avoid being forced to eat stuffed eggs. (An appendectomy was performed.) She had not vomited since that time but was so concerned that she might vomit, that she was unable to be in the vicinity of sick people, or enter rooms where they had been. She could not chew gum, eat a large variety of foods, work with children, or care for her husband when he was sick. She desired but did not have children because she “couldn’t care for them properly.” Her parents considered her concern to be “sillly,” something she would outgrow. (p. 293)
After vomiting the woman:

Quote 2: said that she was now less afraid of vomiting since “after all, it didn’t kill me” (p. 295)
The paper is perhaps also interesting because of the insights into the woman’s strong desire for control.

Quote 3: Her confrontive nature and her previous unsuccessful experience with nondirective therapy suggested the use of a highly directive approach. Her challenging nature was accepted and she was challenged in return. (p. 294)

Quote 4: The basic strategy of this session was the paradoxical technique of “encouraging resistance.’’ Since I agreed with her that she might not continue she could not “defeat the therapist’’ by discontinuing. (Following treatment she said that she felt challenged to prove to me that she could go through with the procedure.) (p. 295)

Brief, Intensive Behavioral Treatment of Food Refusal Secondary to Emetophobia
(Williams, Field, Riegel, & Paul, 2011)

This study describes the treatment of an 8-year-old girl who developed emetophobia and food refusal after an acute illness.
The paper gives some potentially useful background information on emetophobia.

Quote 1: Emetophobia, a fear of vomiting, is a specific phobia that is not yet well documented, and the treatment of this phobia is reported in only a handful of studies. Although it has been suggested that emetophobia is a form of social phobia as many persons with emetophobia exhibit a phobic avoidance of situations that could lead to vomiting (Marks, 1987), it has also been suggested that the fear of vomiting is a variation of a panic disorder (Lydiard, Laraia, Howell, & Ballenger, 1986). When found in children, emetophobia has been hypothesized to be a form of separation anxiety (Klonoff, Knell, & Janata, 1984). A fear of vomiting may be a variant of these anxiety disorders, but, like a fear of choking, emetophobia can also result from direct experience and have an acute onset (Chatoor, Conley, & Dickson, 1988; Nock, 2002). The few studies detailing treatments for emetophobia have involved various forms of exposure or desensitization (Dattilio, 2003; Klonoff et al., 1984; Phillips, 1985). Although most studies describing interventions for emetophobia have described adult participants, one exception is a recent study detailing the treatment of a 7-year-old girl diagnosed with generalized anxiety disorder and fear of vomiting (Whitton, Luiselli, & Donaldson, 2006). The participant in this study did have problems with eating but frequently reported stomachaches and exhibited impairments in social functioning secondary to her anxiety disorder. The characteristics of the participant in the study by Whitton et al. (2006) were similar to those reported by a study that included 56 self-reported emetophobics (Lipsitz, Fyer, Paterniti, & Klein, 2001). The majority of these emetophobics reported other comorbid anxiety disorders, especially panic attacks, and many reported gastrointestinal symptoms. Like the participant described in the study by Whitton et al., the participant in this study also had emetophobia, but unlike the participant in the study by Whitton et al., the participant in this study did not have anxiety problems beyond the fear of vomiting. (p. 304)
The paper also describes the presentation of emetophobia in the 8-year-old girl as well as the causal and maintaining factors. An exposure treatment was utilised, which involved encouraging the child to try foods, whilst ignoring any unhelpful vocalisations and behaviours from her.

Quote 1: The participant was an 8-year-old White female who presented with total food refusal and gastrostomy tube dependence. She lived with her biological parents and her 6-year-old brother. Beyond her current presenting problem, the participant’s family reported no other significant stressors such as chronic health issues, developmental delays, or conflicts between family members. The participant was enrolled in the local public school system and her parents reported that she excelled academically. (p. 305)

Quote 2: The participant stopped eating 4 months prior to the onset of treatment after an acute gastrointestinal illness during which she experienced multiple episodes of vomiting. (p. 305)

Quote 3: The participant reported she refused to eat or drink because “it would make me throw up.” She had even stopped swallowing her own saliva in the belief that the swallowing of saliva could lead to vomiting. The participant reported no other fears. Her parents reported no other anxiety or psychological issues. During this evaluation, she was asked to consume a sip of water (approximately 2 cc), which resulted in a 40-min tantrum. She eventually swallowed the water without gagging or vomiting. Her parents reported this extreme reaction as typical when she was pressed to eat or drink. (p. 305)

Quote 4: Prior to the acute onset of her vomiting phobia and subsequent feeding problem, the participant had no history of mental health problems. Her medical history was significant for only minor acute illnesses typical in childhood. The participant had no history of delays in development, performed well academically, and never required any academic support services. Her parents reported that prior to her illness she ate a wide variety of foods. No family history of anxiety or psychosocial stressors was reported by the parents. (p. 306)

Quote 5: Although the participant’s vomiting phobia and subsequent food refusal appeared to be negatively reinforced avoidance behavior, the fact that she received all of her nutrition through gastrostomy tube feedings was probably a factor that maintained the food refusal. As the tube feedings met 100% of her nutritional needs, hunger did not motivate her to eat. It was also probable that the food refusal was, to some degree, attention maintained, as the participant received a great deal of attention from her parents in the form of frequent requests for her to eat or drink (and probably emotional reactions to her refusal as well). Based on this conceptualization of the problem, it was decided to use an exposure-based intervention that had previously been successful at treating children with extreme food selectivity (Paul, Williams, Riegel, & Gibbons, 2007). One of the participants treated by Paul and her colleagues was a young girl with autism spectrum disorder who refused everything except sips of water. Paul and her colleagues introduced novel foods by requiring the children in their study to repeatedly taste small bites of food. It was hypothesized that this type of repeated exposure could be a successful method of reintroducing foods and addressing the emetophobia experienced by the participant in this study. (p. 306)

Quote 6: Although not required to taste or consume any of the foods or drink, she was praised if she did eat or drink. All inappropriate behaviors and vocalizations were ignored. (p. 307)

Quote 7: The participant was discharged after 7 days of treatment. At a 3-month follow-up visit, she remained free of tube feedings and her intake was sufficient to support normal weight gain. Her BMI was 14.6 and her BMI percentile had increased from the 6th to the 13th percentile, this was close to her pre-illness BMI of 16th percentile. Her mother reported that her daughter no longer verbalized a fear of vomiting and had no problems with eating. (p. 309)

Quote 8: Despite being dependent on tube feedings prior to treatment, the participant quickly increased her oral intake and the need for tube feedings was quickly eliminated. Although the repeated exposure to the tiny amounts of food in taste sessions probably played a role in quickly changing the child’s behavior, it is also likely that the elimination of the supplemental tube feedings produced a strong motivation for her to begin eating. Across the course of treatment, the participant received attention contingent on appropriate behaviors during both meals and taste sessions. Although the role of this contingent attention is unknown, it is expected that prior to treatment, the participant received considerable attention for refusal and other inappropriate mealtime behaviors. (p. 310)

Autobiographical memories of vomiting in people with a specific phobia of vomiting (emetophobia)
(Veale, Murphy, Ellison, Kanakam, & Costa, 2013

This study explored emetophobes’ memories of themselves and others vomiting.

Quote 1: People with SPOV recalled the memories of their own and others vomiting experiences from an earlier age and rated them as significantly more distressing than the control group. There was no difference between the groups in the number of memories of their own vomiting recalled before the age at which vomiting became a problem. However, the SPOV group recalled more memories of others vomiting before the onset of the problem. After the age at which the phobia became a problem they recalled less memories of their own vomiting and more memories of others vomiting than the control group. They recalled significantly more memories of vomiting associated with inter-personal events, health or emotional or unrelated life events. (p. 14)

Quote 2: The origins of SPOV are unknown. There are several competing hypotheses for the origins of phobias in general. Associative theories suggest that phobias develop as a consequence of relevant associative learning experiences (Coelho & Purkis, 2009). Watson and Rayner (1920) originally argued that specific phobias are simply intense classically conditioned fears that develop when a neutral stimulus is paired with a traumatic event, such as when Little Albert acquired an intense fear of rats after hearing a frightening gong paired with the presence of a rat several times (Mineka & Zinbarg, 2006). Several studies have confirmed that many people with specific phobias can recall a traumatic conditioning event when their specific phobia began (see Muris & Mercklebach, 2001, for a review). However, these studies were based on retrospective recall, and therefore it is likely that there are interpretive biases in people’s recollection of events (Mineka & Öhman, 2002). One case series showed that children developed a fear of nausea and vomiting shortly after a stomach virus or medical procedure (e.g. surgery), which had led to vomiting (Klonoff, Knell, & Janata, 1984). To account for the observation that many people with specific phobias do not appear to have had any relevant history of classical conditioning, Rachman (1978) suggested vicarious learning could also be a route for associative learning. He argued that simply observing others experiencing a trauma or behaving fearfully could be sufficient for some specific phobias to develop. The results of some retrospective studies support this idea (e.g. Muris & Mercklebach, 2001; Ost & Hugdahl, 1981). One such case involved a boy who had witnessed his grandfather vomit while dying; shortly afterwards the boy developed SPOV.
Non-associative theories of fear acquisition suggest that some fears (e.g. a fear of heights, strangers, loud noises or water) develop without any critical learning experiences (Poulton, Davis, Menzies, Langley, & Silva, 1998; Poulton & Menzies, 2002a). For example, Poulton et al. (1998) conducted a longitudinal study examining the relationship between conditioning events (before the age of 9 years) and the presence of height fear (at ages 11 and 18 years) and found no positive relationship between relevant traumatic events (e.g. head injury) and fear of heights. In fact, falls resulting in head injury between the ages of 5 and 9 occurred more frequently in those without a fear of heights at 18, a finding in the opposite direction to those predicted by associative theories. In this case, a response of fear may be acquired through evolution and innate pathways, and may have had the evolutionary advantage of avoiding dangerous situations or objects (Poulton & Menzies, 2002a, 2002b). It is hypothesised, however, that an innate pathway would be less likely in SPOV since vomiting allows harmful toxins to be purged and a response of fear is therefore not evolutionary advantageous. (p. 15)

Quote 3: Specifically, it was found that people with SPOV compared to a control group rated the memories of vomiting as more distressing and were more likely to associate the memories with aversive consequences. When age of onset of the phobia was statistically controlled, there was no difference between the SPOV and control groups in the number of episodes of their own vomiting recalled before the age at which vomiting became a problem. Contrary to our hypothesis, after the age of onset of their phobia, they recalled less memories of their own vomiting compared to the control group. However, in terms of memories related to others vomiting, people with SPOV recalled more memories of vomiting than the control group. Even when age of onset was accounted for, the SPOV group still recalled more experiences of others vomiting. If the number of memories of their own vomiting was related to the actual number of experiences of vomiting, then the SPOV group appeared to be somewhat “successful” at reducing the frequency of their own vomiting with one less episode of vomiting every 9.8 years compared to the control group. In favour of this explanation, there were no significant differences between the groups in the number of memories of vomiting before the age of onset of the phobia. This supports the hypothesis that people with SPOV engage in excessive vigilance and avoidance behaviours of cues to vomiting after the onset of their phobia. This therefore reinforces the hypervigilance for cues to vomiting and that this may be a factor in reducing the frequency of vomiting. Specifically it suggests that people with SPOV tend to engage in avoidant behaviour of nausea symptoms because of fear these symptoms may place them at risk of experiencing nausea attacks (Boschen, 2007). However the strategy to reduce the risk of vomiting may cause a significant cost in the quality of life and interference in social life and relationships (Veale & Lambrou, 2006). The control group may have a memory bias against recalling their own vomiting, as they were more likely to have forgotten about some episodes of vomiting compared to the SPOV group (p. 18)

Quote 4: The finding that people with SPOV recalled more memories of others vomiting could support vicarious learning processes of fear acquisition (Rachman, 1978). The experiences of others vomiting were more distressing and were also associated with more aversive consequences. It is possible that people with SPOV might have been more exposed to others vomiting than controls. However a memory bias is likely to occur in the control group recalling memories of other people vomiting. The SPOV group is likely to selectively attend to others vomiting and the control group is more likely to have forgotten episodes of other people vomiting compared to their own vomiting. Indeed only 23.6% of the control group could ever recall another person vomiting compared to 87.4% of the SPOV group. This suggests that the SPOV group is more aware of others vomiting (or people who may be at risk of vomiting) than the control group. This may be due to a variety of reasons. It may be due to selective attention and hypervigilance towards threat stimuli, as reported to occur in general cognitive models of phobias (Beck, Emery, & Greenberg, 1985) and demonstrated in specific phobias. For example, Rinck and Becker (2006) conducted an eyetracking study in people with spider phobia and found an early reflexive attentional bias towards threat, which was followed by avoidance. It may also be the case that individuals with SPOV have a bias towards retrieval of generally negative memories in comparison with the control group, as has been found in previous research examining autobiographical memories in fearful individuals (e.g. spider, or blood/injury) and non-fearful individuals (Wenzel, Jackson, Brendle, & Pinna, 2003). However, if the excessive vigilance and avoidance behaviour is effective in reducing the frequency of their own vomiting, it does not appear to be effective in reducing their contact with other people vomiting. In this case, the selective attention to others vomiting and a memory bias in recalling others vomiting may contribute to the difference observed between the groups.
It was also hypothesised that the SPOV group was more likely to make associations with vomiting and that one of the origins of SPOV could be through associative learning. The SPOV group was more likely to recall a wide range of associations from inter-personal and health or emotional consequences. Interestingly, the associations with others vomiting were also more likely to occur with an unrelated life event. Although unrelated life events were associated only with others vomiting, this has not previously been identified as a possible pathway for associative learning in the acquisition of phobias.
The SPOV group recalled their own memories of vomiting to be more distressing than the controls. They also recalled others vomiting at a younger age and reported a greater level of distress compared to the control group. People with SPOV who mainly feared others vomiting could recall more distressing memories of others vomiting rather than their own vomiting. (p. 18)
The data support an associative model of learning in a specific phobia of vomiting, perhaps from both direct experiences of vomiting (Watson & Rayner, 1920); social learning (Bandura, 1977) and vicarious learning (Rachman, 1978). Further research, which explore patients’ imagery and associations of memories of vomiting through in depth interviews are needed to further develop this line of research. It could also explore whether the memories prior to the onset of the phobia have more meaning and associations than those after the onset of the phobia (Price, Veale, & Brewin, 2012). (p. 19)
The memories of others vomiting in the current study include reports of observing the fear or disgust response of others. Children may obtain emotional information from their caregiver to appraise an uncertain situation (Feinman, 1992). Social referencing may therefore be the basis for vicarious learning of fear and disgust that potentially contributes to the development of SPOV. Furthermore, some distress or aversive consequences with one’s own or others vomiting may be normal and there may be an unknown protective factor in people who do not go on to develop a phobia. Van Overveld, de Jong, Peters, van Hout, and Bouman (2008) found that people with SPOV have a higher level of disgust sensitivity and this may make an individual at greater risk of developing SPOV. Disgust sensitivity has been proposed to play a role in the aetiology of a number of anxiety psychopathologies, including spider and small animal phobias and blood/injury phobias (Davey, 2011). Therefore, it is possible that the people with SPOV, particularly the subgroup that mainly fears other people vomiting, are more prone to disgust sensitivity as they develop fears of contagious disease from others. Davey and Hurrell (2009) also hypothesised that the experience of disgust may activate anxiety sensitivity; that is, fear of one’s own bodily sensations and perhaps losing control. Further research is required to determine if the people with SPOV have greater disgust sensitivity prior to the onset of the phobia or if it develops as a symptom after the onset of the phobia. (p. 19)

PREVALENCES FOR EMETOPHOBIA FROM THE RESEARCH

The point prevalence rate of fear of vomiting was 8.8%. (Hout & Bouman, 2011)

Only two studies (Philips, 1985; Becker et al., 2007) reported prevalence estimates for fear of vomiting. Philips (1985) found prevalence figures of 3.1% for men and in 6% for women in the USA. Findings from the Dresden Mental Health Study found a lifetime prevalence rate of 0.2% and a point prevalence of only 0.1% in female participants. (as cited in Hout & Bouman, 2011, p. 537)
Male versus female
In a random Dutch community sample, fear of vomiting was present in 1.8% of the men and in 7% of the women. (Hout & Bouman, 2011) (i.e. around 80% of emetophobes were female)
Respondents (n=56) were 89% female. (Lipsitz et al., 2001)
Participants (n = 100) were 97% female (Veale & Lambrou, 2006)

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