Cognitive Therapy for Emetophobia
Abstract:
This article proposes a cognitive model for the understanding of Emetophobia, its maintenance and treatment. Emetophobia (the fear of vomiting) is often conceptualised through conditioning or trauma‑fusion models. While these treatments have been shown to be effective, there is a lack of choice for patients regarding treatment, meaning that if treatment has been unsuccessful, clients are often forced to look for less evidence based strategies for which the internet is happy to provide. This leads to considerable frustration, financial cost and the prolonging of distress of those suffering from emetophobia. Current models mainly focus on the use of exposure and response prevention (ERP) which is rooted in behavioural therapy and doesn’t focus on the cognitive mechanisms behind the disorder. This article proposes a cognitive model for emetophobia which is hoped to provide an alternative treatment for when ERP therapy has not been effective or when clients struggle to engage. The clinical implications of this is that cognitive therapy may be more acceptable than ERP‑heavy protocols which can sometimes suffer with client drop out and can feel intimidating for patients to engage in.
Introduction
The specific phobia of vomiting (also known as emetophobia) is a greatly debilitating phobia which can affect every area of the sufferer's life. Unlike most specific phobias, where the sufferer can easily avoid their phobic object, those with emetophobia are fearful of internal sensations and a reflex action (vomiting) which is outside of their control or ability to avoid. The prevalence of emetophobia has been estimated to be up to 8.8% of the population (van Hout & Bouman, 2011). Despite this high prevalence rate, Emetophobia remains an under-researched disorder (Veale & Lambrou, 2006)
The most used treatment protocol for Emetophobia is CBT. This is usually split between behavioural based therapies using exposure and response prevention (ERP) (Craske et al., 2006) or the Veale protocol (Veale, 2009) which is based on the theory that past aversive memories of vomiting become associated with fear and the development and maintenance of emetophobia. One potential issue of basing treatment on traumatic past memories of vomiting is that some patients with Emetophobia fail to report or remember a distinct early memory of vomiting. A small proportion of the population also report not experiencing mental imagery, known as Aphantasia. To the authors knowledge there has been no research into whether or not those with Aphantasia are immune or still experience emetophobia.
The problem with exposure based therapies is that whilst patients often understand the rationale and are satisfied with the treatment (Cox et al., 1994), it often has a PR problem (Richard & Gloster, 2007) and some patients find the idea of exposure therapy distressing (Lipsitz et al., 2001). There has recently been a rise in anti exposure based therapies in the online community which has been enhanced and promoted by the use of social media by groups offering non-exposure based therapies for emetophobia. These groups strongly promote the message that exposure therapies do not work for emetophobia and many emetophobic clients have heard and repeat these messages in online groups. This can lead to the avoidance of treatment. When exposure based interventions are used, some patients struggle to habituate to their anxiety (Pence et al., 2010) or that exposure to situations linked to vomiting is hard to achieve. Exposure therapy is also slower to treat the emotions of disgust (Ludvik et al., 2015) which can be highly prevalent in emetophobia.
This article aims to introduce the idea that Emetophobia can also be understood as a disorder of cognition linked to perception rather than a disorder of conditioning or trauma memories. This approach is called Cognitive Therapy for Emetophobia.
The Cognitive Model of Emetophobia
The cognitive model proposed is made up of conceptualising emetophobia in three main “layers” and uses a vicious flower formulation as a basis for treatment.
Layer 1 is the core of the patient’s problem and reflects the patient's inflexible and catastrophic “global negative perception” of vomiting, nausea, anxiety, and uncertainty.
Layer 2 is the patient's vicious cycle in response to triggers. Repeated activation of this layer feeds the patients “global negative perception” of vomiting, nausea, anxiety, and uncertainty.
Layer 3 is the behavioural maintenance processes which directly influence and maintain the previous two layers.
Layer 1: The patients “global negative perception” of vomiting:
The first layer of the conceptualization is labeled as the patient’s “global negative perception” perception of vomiting and explores the patients appraisals as vomiting as well as nausea, anxiety, uncertainty and the need for control. This global perception is best visualised using a tool called the anxiety equation which is often used for other cognitive models such as for OCD (Salkovskis, 1985) or Illness anxiety (Salkovskis et al., 2003).
This equation will be idiosyncratic to each patient but usually shows that the patient has over inflated the severity and likelihood and minimised their own ability to cope and be supported (also known as rescue).
Severity:
Those with Emetophobia often have highly catastrophic perceptions of vomiting, nausea, having a high level of anxiety or feeling a lack of control. Patients can fear the physical sensations of nausea, tightness in the throat or other anxiety symptoms (Craske, Barlow and Antony, 2006) and perceive them as dangerous, unacceptable or intolerable. The act of vomiting itself can be appraised as awful, dangerous or disgusting which heightens its perceived severity. Often vomiting is imagined to be truly awful, prolonged, frequent, uncertain and should be avoided at all costs. Often appraisals around vomiting can focus on social judgment or stigma regarding vomiting in public. Some patients believe vomiting is dangerous, lasts forever, or can even lead to death. It is not uncommon for patients to view vomiting as 100% awful and even prefer death to vomiting (Veale, 2009).
If appropriate to the patient, the appraisals of the perceived severity of nausea, anxiety, uncertainty and the need for control can also be incorporated into the equation. Nausea is often seen as a warning or precursor of vomiting, or be seen as intolerable, uncontrollable and that it may last for hours in its own right. Appraisals linked to anxiety can be very important as many patients have distress tolerance and experiential avoidance around feeling anxious or panicked. A minority of emetophobics can perceive the feeling of anxiety when vomiting as worse than the action of vomiting itself. They often believe if they were to vomit, they will panic, shake, be out of control or unable to handle their extreme level of anxiety. Patients may also have appraisals about uncertainty and control. This is similar to appraisals seen in the Intolerance of Uncertainty Model (Robichaud et al., 2019) for Generalised Anxiety Disorder (GAD).
Likelihood:
Those with emetophobia often overinflate how likely vomiting and each specific prediction made in their severity section is to occur.
Coping:
Patients with emetophobia often have a reduced perception in their ability to cope with vomiting, nausea, anxiety or uncertainty. Often this is due to the heightened catastrophic appraisals from their severity section. The more severe the predicted outcome, the harder it is to visualise effective coping. It is not uncommon for those with emetophobia to feel like vomiting is “the end of the world” due to not having any self-confidence in their ability to tolerate or get through the experience.
Support:
The last part of the anxiety equation relates to how patients perceive the support others can or cannot provide if their fears were to occur. In cases where the patient's fear revolves around social judgment or others, support from others is the last thing they want. In some cases patients can perceive a high level of support from others, usually if friends and family members regularly engage in accommodation of safety behaviours.
Conclusion:
This anxiety equation helps form the basis of understanding the patient's global negative perception of vomiting and is the first layer in the cognitive formulation of emetophobia. Treatment revolves around re-appraising these beliefs to a more balanced, less threatening view of vomiting.
Layer 2: The vicious cycle when triggered.
The second layer to the cognitive conceptualisation of emetophobia, represents how the patient responds emotionally, physically and cognitively to a triggering situation. Due to the patient's global negative perception of vomiting, when a patient with emetophobia faces a trigger, it will kickstart a chain reaction similar to this:
Each patient will have their own different idiosyncratic experience and this should be reflected in their own formulation. However, usually four areas occur:
1) Thoughts: In response to the trigger, the patient will start to have thoughts that validate that they are under threat.
2) Anxiety: Due to these thoughts, the patient's fight and flight system responds to the perceived threat and they naturally feel anxious. This anxiety can feedback into producing more anxious thoughts.
3) Mental Imagery: When the fight or flight response activates, the body naturally orientates itself towards the perceived threat. Due to Emetophobia being an internal and future based threat, the mind often produces a mental picture of vomiting to better visualise and comprehend the threat. This can either be a memory of a past traumatic incident of vomiting or can be a picture of what they fear is about to occur. These mental images increase anxiety and act to validate the patient's thoughts about the current ‘threat’ of vomiting. As previously mentioned, there is a small percentage of the population who can't see or struggle to see clear images in their mind and may skip this step.
4) Physical sensations (i.e nausea and gastrointestinal symptoms): A large majority of those with Emetophobia report experiencing nausea and gastrointestinal symptoms regularly. This can be a direct consequence of this vicious cycle. Mental imagery and thoughts of vomiting or contamination can prompt the defensive emotion of disgust and result in the feeling of nausea. Anxiety (due to the fight and flight response) can also cause nausea as a side effect. The presence of gastrointestinal symptoms is often appraised as confirmation of the risk of vomiting and reinforces the patient's anxious thoughts, leading to more anxiety, which perpetuates the cycle. Depending on the patient's idiosyncratic anxiety equation, patients often report other anxiety symptoms for which they personally find distressing in addition to nausea. These symptoms can also be placed in this section.
These four components often become a vicious cycle, which over time reinforces the patient's global negative perception of vomiting. This cycle can be represented visually like this:
The arrows on the cycle above do not represent all of the possible interactions between these distinct areas but are designed to show the cyclical nature of this cycle. Layer two could technically be visualised to better show the links similar to this and resemble a four areas model:
Layer 3: Behavioural Maintenance Processes
The last layer in the cognitive conceptualisation for emetophobia is the maintenance of the first two layers. The maintenance of these layers is hypothesised to be due to the patients excessive use of safety behaviours designed to try and reduce the risk of vomiting. Safety behaviours are any action taken to reduce the chance of vomiting or manage anxiety.
These safety behaviours can be split into various categories:
Actions taken to verify danger and the chance of vomiting:
Checking behaviour.
Reassurance seeking.
Self-focused attention.
Hypervigilance.
Behaviours to avoid or escape vomiting:
Avoiding cues related to vomiting.
Avoiding physical sensations.
Cognitive avoidance.
Avoiding places and situations.
Actions actively taken done to prevent vomiting:
Preventative safety behaviours.
And mental strategies:
Worrying.
Mental planning.
Positive Affirmations/Mental debate.
Distraction.
This is not an exhaustive list and safety behaviours will be idiosyncratic to the patient in question.
Cognitive therapy for emetophobia views these behaviours as a maintaining factor due to:
1) They maintain the global negative view of vomiting in ‘layer one’:
These behaviours unintentionally confirms the patients appraisals in their ‘global negative perception’ that vomiting is catastrophic, highly likely, and something they could not cope with or be supported through.
2) They directly activate and maintain the vicious cycle in “layer two”:
When someone uses these behaviours, they immediately influence what happens in the second layer of the model. This occurs in three ways:
1) Directly cause the four areas in layer 2: Safety behaviours often can directly cause or increase the intensity of thoughts, anxiety, mental imagery or physical symptoms. For example, the behaviour of self-focused attention can increase the likelihood of noticing nausea (which starts the vicious cycle) or amplify its intensity (amplifies the cycle when already activated).
2) Short term relief: Secondly, these behaviours have the ability to stop or reduce thoughts, anxiety, mental imagery or physical symptoms in the short term, leading to a sense of temporary relief. This temporary relief acts to reinforce and validate the original risk of vomiting, causing the behaviour to be repeated for future triggers as it is now appraised as helpful.
3) Increase preoccupation: Lastly, the use of these behaviours increases pre-occupation with vomiting.
3) These behaviours are appraised as helpful, which becomes self reinforcing, thereby maintaining “layer three”:
Each safety behaviour will have appraisals about their helpfulness. As the behaviour feels functional in the moment, it becomes more likely to be repeated, even when it keeps the overall problem going. Treatment involves testing the accuracy of the helpfulness of these behaviours. The helpfulness of safety behaviours is resistant to being naturally re-appraised due to the tendency for their use to prevent disconfirmation of the original feared outcome. This has been well documented in the literature and is often explained using analogies such as ‘the builders apprentice’, ‘elephants on the track’, ‘vampires and garlic’, or ‘dragons and salt’.
Not all patients will engage in each safety behaviour and the appraisals about the helpfulness of each safety behaviour will be idiosyncratic to the patient but often follow the similar theme of preventing vomiting or reducing anxiety.
These unhelpful behaviours can be visualised as feedback loops on a vicious flower:
Cognitive Therapy Treatment Protocol:
Treatment aims:
Based on the cognitive model of Emetophobia, treatment focuses on the re-appraisal of all three layers of the formulation, with the largest focus being on the elimination of safety behaviours.
This is the priority as these behaviours are
Maintaining the patient's global negative perception (Maintaining layer 1).
Causing their vicious cycle (Maintaining layer 2).
Are self-reinforcing (Maintaining layer 3).
The aim of treatment is not about learning to tolerate vomiting or anxiety. It is about:
Disconfirmation of the helpfulness of their safety behaviours.
Re-appraising the likelihood of vomiting from likely to a rare occurrence.
Re-appraising the severity of vomiting, nausea, anxiety and uncertainty.
Re-appraising the patients ability to cope and be supported if vomiting was to occur.
Re-attributing nausea as a symptom of anxiety and the disgust response and not an indicator of vomiting (in most cases).
Treatment should involve:
A collaborative formulation of the layers of cognitive conceptualization.
Using ‘Theory A and Theory B’ to shift the focus of therapy from vomiting being the problem to the true problem being the patient's "interpretation" of vomiting
Using behavioural experiments that are designed to test the need for safety behaviours.
Using behavioural experiments to overcome avoidance.
Shifting towards acceptance of vomiting once it has been appraised as less severe.
Formulation:
The first few sessions of the protocol should focus on formulation and setting up ‘Theory A and B’. The rest of the therapy is formulation led and should be based around the patient's idiosyncratic formulation.
The first session should focus on using the anxiety equation as a framework to explore the patient's appraisals (layer 1). Once this has been completed, a recent example of the patient's distress can be explored to formulate their vicious cycle (layer 2). This should be done briefly and with the aim to help the patient objectively see that their experience is made up of various components which all interact and can fuel each other. Following this, a vicious flower can be completed to explore the safety behaviours the patient uses to verify, monitor, plan for and prevent vomiting, nausea, anxiety or uncertainty (layer 3). For each behaviour, a socratic discussion should be had on how it directly influences the vicious cycle in layer two and what it does to their global negative perception (anxiety equation) in the long run. This helps shift the patient from seeing the behaviours as helpful to recognising their long term role in maintaining the problem.
Theory A and B:
Following formulation, the concept of acting like scientists during therapy should be had. The patient and therapist embark on the task of collaboratively and scientifically proving or disproving the patient's global negative perception of vomiting using “Theory A and B” as a framework to collect and analyse the data. Theory A and B is the act of creating two opposite hypotheses to explain the patient's problem.
Theory A represents the idea that vomiting truly is awful and should be avoided. This should echo the patient's anxiety equation (layer 1).
Theory B represents the idea that instead of vomiting being truly awful, the patient has an interpretation problem and that they have simply convinced themselves that vomiting is awful when it is in fact safe and less likely than they think. Theory B states that this interpretation problem is the result of all of the ways they are trying to monitor and prevent their fear from occurring.
For both these theories, a discussion should be had on:
What evidence supports each theory. Poor quality evidence can be socratically challenged at this point.
How the patient would be required to act day to day if the theory was true. For theory A, this outlines that all the patients’ safety behaviours are rational given the theory. Theory B acts like a roadmap to non-phobic behaviour and shows that if the problem was an interpretation problem then their safety behaviours are irrational.
The long term impact on the patient's life for believing each theory. For theory A this often shows how bleak, scary and impacted their life will always be, while Theory B leads to freedom from anxiety and a less impacted, happier life.
The aim of this tool is not to convince the patient in theory B. It is to provide a platform to re-appraise layer 1 of the formulation. Each following behavioural experiment or therapy tool should provide evidence to support one of these theories being true, giving the patient a chance to test and prove the two theories through direct experimentation and action.
Behavioural experiments:
The rest of the therapy should be formulation led. Treatment should involve selecting a safety behaviour, understanding the appraisals underpinning its helpfulness and using behavioural experiments to test the accuracy of these appraisals.
Due to the use of experiments, no exposure hierarchies are needed. Experiments should involve direct exposure with patients facing a triggering situation in the absence of the targeted safety behaviour. While these experiments test the helpfulness of the behaviour, all experiments should be linked back to Theory A and B to slowly reappraise the patient's global negative perception of vomiting. For behaviours related to avoidance (cues, situations and cognitive avoidance etc), behavioural experiments should be used over ERP. Although both experiments and exposure highly overlap, it is important that the learning from doing so is not about toleration and habituation, but on the need to avoid the trigger in the first place.
In addition to safety behaviours, treatment can focus on:
Flash backs: If the patient is experiencing flashbacks of previous episodes of vomiting, the use of either using imaginal reliving (Ehlers & Clark, 2000), imagery rescripting (Arntz & Weertman, 1999) or the “compassionate nurturer” can be used.
Flash forwards: Imagery can be a central component in emetophobia and patients often appraise mental images as dangerous as they feel they can lead to extreme anxiety or an increased chance of vomiting. The appraisals behind these images can be assessed and appraised using imagery manipulation, narrative exposure (as an experiment) or using defusion from acceptance and commitment therapy among other methods.
Physical sensations: Catastrophic appraisals behind avoided or distressing symptoms should be assessed and re-appraised. This can be done similar to symptoms in panic disorder (symptom induction) or by behavioural experiments.
Acceptance: Later in treatment, acceptance work can be introduced with the aim of helping the patient to focus on improving their life and not engaging in safety behaviours. This can include elements from acceptance and commitment therapy. In particular, defusion and committed action.
Reappraisals of severity and coping: Those with emetophobia often avoid thinking about vomiting which maintains appraisals of severity and the inability to cope. These appraisals are resistant to change when they are being suppressed. To overcome this, narrative exposure can be used but with the aim acting like an experiment to overcome the appraisals around avoidance of thinking of vomiting. Once the patient is able to think through and visualise their fears, they often automatically reality test how catastrophic it is.
Reappraisal of nausea: Nausea is often seen as a precursor for vomiting despite the fact patients have had repeated episodes of nausea in the absence of vomiting. Psychoeducation on how disgust, thoughts, mental imagery and anxiety produce nausea. Nausea can be appraised as non-threatening and experiments can be used to disconfirm the dangerousness of the symptom.
Many of the tools used focus on reducing safety behaviours which often successfully re-appraises the likelihood of vomiting. However, many patients can recognise this but still feel fearful if vomiting was still to occur. The end stage of treatment needs to focus on truly acting in line with Theory B and accepting that vomiting is a natural part of life. This can be achieved by not only reducing avoidance but actively facing feared situations and focusing on valued based living.
Conclusion
Emetophobia has long been conceptualised through the lenses of conditioning, trauma‑fusion, or exposure‑based learning. While these frameworks have contributed valuable clinical tools and are effective, they do not place emphasis on the cognitive mechanisms that explain the maintenance of the disorder. Having another model can be helpful for patients with unidentifiable trauma memories or when habituation is unsuccessful during exposure based therapies. The cognitive model proposed in this article reframes emetophobia as a problem of catastrophic appraisals. By organising emetophobia into three interacting layers; a global negative perception, the vicious cycle, and the behavioural maintenance, this cognitive model offers a coherent explanation for how the fear is caused, triggered and maintained. This model highlights that the core problem is not vomiting itself, but the meaning patients attach to vomiting, nausea, anxiety, and uncertainty. These appraisals drive the physiological and emotional responses that patients misinterpret as evidence of imminent danger, and then motivate a wide range of safety behaviours that inadvertently reinforce and validate the fear in the long term. Although this model is currently untested and empirical research is needed to test this model and compare cognitive therapy with existing CBT and ERP‑based protocols, the theoretical and clinical foundations outlined here are similar to other successful cognitive protocols such as that for Social Anxiety Disorder (Clark, 2001), PTSD (Ehlers & Clark, 2000), Panic Disorder (Clark & Salkovskis, 2009). It is my hope that the cognitive‑therapy approach in this model provides an alternative to ERP. Rather than only relying on exposure and habituation, treatment can focus on collaboratively testing appraisals, reducing the perceived usefulness of safety behaviours, with the aim of changing the patient’s global negative perception of vomiting. This ‘scientific’ approach used in theory A and B is likely to be more acceptable to patients, reduce dropout, and improve engagement compared to exposure based treatment.
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