Great choice.
You can do this!
Aims:
So, we know that avoiding these cues only makes your phobia worse in the long term. So we need to overcome this.
We do this by testing out these two ideas:
Idea 1: You think it will lead you to feel nauseous, which will lead to you being sick.
Idea 2: You think that you will become panicked, out of control or unable to cope.
If you believe these two things, it makes sense why any cues related to vomiting feel scary. However, the fact that these cues do not effect others in this way demonstrates that these beliefs may not be accurate.
If you find out these things are not true, then there is no reason to avoid these cues in the future.
Lets talk about Idea 1:
Idea 1: You think it will lead you to feel nauseous, which will lead to you being sick.
This idea often stems from a common misunderstanding that those with Emetophobia (and most the general population) have about the purpose of nausea. Most people believe that nausea is a warning sign or a lead up to being sick. This idea is actually incorrect.
The big problem with believing this is that any time you feel nauseous, you panic thinking you might be sick. And if you have Emetophobia, it is highly likely you feel nauseous a lot. This false belief makes nausea a threat and feel scarier than it is.
So what is nausea for?
Nausea is linked to our disgust response. Disgust is an emotion that everyone feels and is a very important emotion for survival.
Think of things that cause of to be disgusted:
Rotten food.
Bad smells.
Infections.
Illness.
Sick.
Insects and pests.
Mould and fungus.
Slimy or sticky textures.
Faeces and waste.
Discoloured water.
Dead animals.
Strange or unusual foods.
Can you spot a common theme yet?
The answer:
We feel disgusted by anything that signifies that it would be spoilt, carry germs, be contaminated or make you unwell if you were to eat or get to close to it.
When our disgust response turns on, it causes the sensation of nausea. Nausea is a powerful feeling that is designed to prevent you from eating. Those with emetophobia never consider our disgust response as a cause of nausea and that it is simply a feeling to prevent eating that is rarely linked to being sick. Ask yourself how often you feel nauseous compared to how often you are actually sick. There is most likely as massive gap between those numbers because they simply are not linked. The reason we see them as linked is that nausea is often produced when being sick. But this makes sense, when your body is trying to get food out, it wants you to stop eating. So it produces nausea.
Nausea due to anxiety:
Nausea can also be a unintended side effect of our anxieties “fight or flight” system. When anxious, regardless of the cause, our body gets ready to either fight the danger or run away from the threat as fast as possible. Your body reacts as if you are in a life-threatening situation. All resources get taken away from less vital things like digestion and gets redirected to your muscles. Basically, your body presses the emergency stop button on your stomach.
If your digestive system is turned off, your body wants you to stop eating. So it produces nausea to prevent you from eating. This instant stopping of your digestive system, paired with increased muscle tension and hormonal changes causes nausea as a side effect that as noting to do with sickness.
If you feel nauseous all of the time, it most likely means you are stuck in this fight and flight mode constantly. The main problem is that you most likely perceive this nausea as a sign potential sickness and therefore feel scared of it and see it as a danger. Which then only increases the fight and flight response and causes more anxiety and even more nausea. This creates a loop you can get trapped in.
Why do reminders of sickness cause nausea?
The human brain has the ability to imagine things that are not happening. To do this it uses the same brain regions that would be activated if we were experiencing the thing we imagined.
For example, if you close your eyes and imagine a puppy, your primary visual cortex (the part of the brain that processes real sight) lights up, just like it would if a puppy walked into the room. This isn't just for sight. If you imagine a song, your auditory cortex activates. If you imagine kicking a ball, the motor cortex (which controls movement) primes itself in a similar pattern to an actual kick.
The only difference is in the intensity and the direction of information. When you see a real puppy, the signal goes from your eyes up to your brain. When you imagine a puppy, the signal starts in your memory/higher brain regions and travels down to the visual areas.
This intensity can get ramped up by how much we focus on the thing we are thinking about. If you tell yourself something is a threat, your brain pays more attention to it. If you believe seeing any reminder will cause:
Idea 1: You think it will lead you to feel nauseous, which will lead to you being sick.
Idea 2: You think that you will become panicked, out of control or unable to cope.
Then your anxiety system ramps up (causing nausea) and your thoughts jump to sickness which activates your disgust response (causing nausea).
So it often becomes a self-fulling prophecy. And the more you avoid these reminders, the more anxiety and disgust they cause. Prompting more avoidance.
Reminders are factually safe.
The thing is that these reminders are in fact safe. The best way to break you out of your fear is to prove to yourself that they are safe and that these two ideas are false.
Idea 1: You think it will lead you to feel nauseous, which will lead to you being sick.
Idea 2: You think that you will become panicked, out of control or unable to cope.
If nausea caused by your brain falsely activating your disgust response and doesn’t lead to being sick, then you have no reason to fear or be anxious about reminders of vomiting.
Let’s help you prove this.
How do we test out these ideas?
We can test these ideas out by facing reminders about vomiting in a controlled manner to see what happens. We can start this really small and work our way up.
We will start by looking at words linked to vomiting and then move onto sightly harder categories once you feel ready.
The idea is to help you realis that nothing bad happens from doing this. Yes you might feel a bit nauseous, but that is just your disgust response. It won’t lead to anything.
Doing this helps us prove or disprove these two ideas:
Idea 1: You think it will lead you to feel nauseous, which will lead to you being sick.
Idea 2: You think that you will become panicked, out of control or unable to cope.
Instructions:
When you face your fears it is important that you don’t use any distractions or safety behaviours.
What are safety behaviours:
Safety behaviours are any action you may be tempted to use to prevent your fear from happening or to reduce your anxiety. They act like a safety net to prevent your fear. While they seem harmless or even helpful, these behaviours actually feed your Emetophobia because they prevent you from learning safety.
Let’s demonstrate this using an analogy I like to call “barking at the postman”.
“Barking at the postman”
We all know that most dogs bark at the postman. Lets imagine a dog who is scared of the postman. When the postman comes close to the house, the dog perceives a threat. The dog thinks that the postman is going to break in or is a danger in some way.
So the dog barks!
And the postman walks away.
The dog congratulates himself on getting rid of the threat. He learnt that barking keeps the postman away. Good boy!
However, we all know the postman would have walked away on his own. Each time the dog sees the postman he still sees him as a threat and barks. He thinks his barking is working.
Now imagine you could speak with dogs and you ask him to take a “risk” and not bark at the postman for the week.
The dog watches the postman coming and does not bark. To his surprise the postman posts his letter and walks away… He thinks “maybe I got lucky, I am sure he will break in next time”. The day next comes, and the next day after that. The dog doesn’t bark and the postman still hasn’t broken in. Soon the dog realises he was wrong and that the postman was not trying to break in. Only by changing his behaviour (not barking), did he change his belief about the danger.
Key message:
When we use our safety behaviours we never get to see what would have happened if we did nothing. We are barking at the postman even when he was going to walk away anyway. So, we need to test out our predictions by facing our fear without trying to prevent it.
Remember we are testing out these two ideas:
Idea 1: You think it will lead you to feel nauseous, which will lead to you being sick.
Idea 2: You think that you will become panicked, out of control or unable to cope.
If you face these cues whilst using a safety behaviour, even if your fear doesn’t come true, you will convince yourself it was only because of the action you took. It would make facing these cues pointless.
Lets start:
Below, there will be some words that describe being sick. Shown one at a time. Read the word and really imagine what it means. Allow your mind to think about the concept. You may feel a little anxious or nauseous. That is expected if you have been avoiding these words for a long time or if your emetophobia is severe. But remember, nausea does not mean you will be sick.
Just keep looking at the word until you start to feel bored or have learnt something about the two beliefs we are testing. Depending on how severe your Emetophobia is, you might find this easy or difficult.
Remember not to use any safety behaviours. Only then will you know if these beliefs are true or not (do not bark at the postman).
Keep looking at the word until you feel bored. Then move onto the next word and continue.
Well done!
Learning:
What have you learnt from doing that?
The whole point was to test out two ideas:
Idea 1: ‘You think it will lead you to feel nauseous, which will lead to you being sick’.
You may have noticed you felt nauseous or even that you gagged. But did it lead to vomiting? Most likely not. Why? Because 99.9% of the time, nausea is apart of your disgust response. Not about being sick.
Idea 2: ‘You think that you will become panicked, out of control or unable to cope’.
Did you feel anxious? Probably. But, what happened the longer you did the task? It should have got easier once you realised that reading these words doesn’t lead to being sick.
Keep repeating this exercise until it doesn’t bother you any more.
Hopefully you learn that words are just pictures on a screen. They have no ability to harm you. So they don’t have to be feared.
Now what?
It’s not good enough to just change our thinking. We need to change our actions in the future based on what we have learnt.
Based on what you have learnt, how are you going to react to words linked to vomiting in the future? Are you going to avoid them, or are you able to face them calmy because they are safe?
The next step: Cartoons
So, now we know words are fine to read and think about and that they don’t lead to being sick. We also need to learn this about other reminders. Especially visual reminders. Let’s start with cartoons. Follow the same steps as before.
Again we are testing out these two ideas:
Idea 1: ‘Reminders like cartoons will lead to feeling nauseous, which will lead to you being sick’.
Idea 2: ‘You think that you will become panicked, out of control or unable to cope’.
Another big well done!
Learning:
What have you learnt from doing that?
The whole point was to test out two ideas:
Idea 1: ‘Reminders like cartoons will lead to feeling nauseous, which will lead to you being sick’.
You may have noticed you felt more nauseous than with the words. But that makes sense. Remember how the brain struggles to tell the difference between something that is real and not real. But the real question is, did that nausea lead to vomiting? Most likely not. Why? Because 99.9% of the time, nausea is apart of your disgust response. Not about being sick.
Idea 2: ‘You think that you will become panicked, out of control or unable to cope’.
Did you feel anxious? Probably. But, what happened the longer you did the task? It should have got easier once you realised that viewing cartoons doesn’t lead to being sick.
Keep repeating this exercise until it doesn’t bother you any more.
Hopefully you learn that images on a screen are just pixels on your device. They have no ability to harm you. So they don’t have to be feared.
Now what?
It’s not good enough to just change our thinking. We need to change our actions in the future based on what we have learnt.
Based on what you have learnt, how are you going to react to cartoons in the future? Are you going to avoid them, or are you able to face them calmy because they are safe?
The next step: photographs of people before vomiting
So, now you know cartoons are safe to watch, lets move onto real photographs. The next section will show photographs of people before they are sick, feeling nauseous and even over a toilet bowl but will not show any vomit.
Again, watch each one until bored and don’t use any safety behaviours.
Remind yourself that if cartoons are safe, why would photographs be any different. Both are just pictures. If you start to feel nauseous it is just because you are either anxious or your brain is activating your disgust response because it can’t tell the difference between a picture and something really happening.
Look at how well you are doing!
Learning:
What have you learnt from doing that?
The whole point was to test out two ideas:
Idea 1: ‘Reminders like photographs will lead to feeling nauseous, which will lead to you being sick’.
You may have noticed you felt more nauseous than with the cartoons. But that makes sense. Remember how the brain struggles to tell the difference between something that is real and not real. Photographs are more vivid and can trick the brain more easily. But the real question again is, did that nausea lead to vomiting? Most likely not. Why? Because 99.9% of the time, nausea is apart of your disgust response. Not about being sick.
Idea 2: ‘You think that you will become panicked, out of control or unable to cope’.
Did you feel anxious? Probably. But, what happened the longer you did the task? It should have got easier once you realised that viewing these photos doesn’t lead to being sick.
Keep repeating this exercise until it doesn’t bother you any more.
Hopefully you learn that images on a screen are just pixels on your device. They have no ability to harm you. So they don’t have to be feared.
The next step: photographs of people vomiting
So now lets move onto photographs of people vomiting. This may feel like a big step up, however, it is no different than what you have already done. It is just pixels on your screen, just like the last task. These images might trigger nausea, but again, remind yourself that nausea is not the problem, avoidance is.
Again, view each one until bored and don’t use any safety behaviours.
You are smashing it!
Learning:
What have you learnt from doing that?
The whole point was to test out two ideas:
Idea 1: ‘Reminders like seeing people being sick will lead to feeling nauseous, which will lead to you being sick’.
You may have noticed you felt more nauseous seeing those actually being sick. But again, that makes sense. Remember how the brain struggles to tell the difference between something that is real and not real. But the real question again is, did that nausea lead to vomiting? Most likely not. Why? Because 99.9% of the time, nausea is apart of your disgust response. Not about being sick.
Idea 2: ‘You think that you will become panicked, out of control or unable to cope’.
Did you feel anxious? Probably. But, what happened the longer you did the task? It should have got easier once you realised that seeing these photos doesn’t lead to being sick.
Keep repeating this exercise until it doesn’t bother you any more.
Hopefully you learn that images on a screen are just pixels on your device, even if those pixels are of being throwing up. They have no ability to harm you. So they don’t have to be feared.
Now what?
It’s not good enough to just change our thinking. We need to change our actions in the future based on what we have learnt.
Based on what you have learnt, how are you going to react to photographs or images about sickness in the future? Are you going to avoid them, or are you able to face them calmy because they are safe?
The next step: sounds of people vomiting
So up to know we have worked on your visual cortex (the part of your brain for vision), now it is time to work on your auditory cortex (the part of the brain for sounds).
The next section will play a sound on a loop. These might not be pleasant to listen too. Even people without Emetophobia wouldn’t see this as a nice thing to do. But it is important to be able to hear sounds and realise they even though they are unpleasant, they are safe.
Again, listen to each one until bored and don’t use any safety behaviours.
The point is to test out two ideas:
Idea 1: ‘Reminders like sounds will lead to feeling nauseous, which will lead to you being sick’.
Idea 2: ‘You think that you will become panicked, out of control or unable to cope’.
Sounds played on a loop:
Gagging sounds:
Retching sounds:
Sound of liquid in a toilet (no vomiting sounds):
Vomiting in toilet + retching sounds:
Man vomiting:
With each step, you are moving closer to recovery!
Learning:
What have you learnt from doing that?
The whole point was to test out two ideas:
Idea 1: ‘Reminders like sounds of people being sick will lead to feeling nauseous, which will lead to you being sick’.
You may have noticed you felt more nauseous or disgusted hearing those sounds. That is what our disgust response is for. It is doing its job. But the real question again is, did those sounds lead to vomiting? Most likely not.
Idea 2: ‘You think that you will become panicked, out of control or unable to cope’.
Did you feel anxious? Probably. But, what happened the longer you listened to those sounds? It should have got easier once you realised that listening to those sounds doesn’t lead to being sick.
Keep repeating this exercise until it doesn’t bother you any more.
Hopefully you learn that sounds, even though they are unpleasant, are safe to listen to. They have no ability to harm you. So they don’t have to be feared.
Now what?
It’s not good enough to just change our thinking. We need to change our actions in the future based on what we have learnt.
Based on what you have learnt, how are you going to react to sounds in the future? The point is to also apply this to real sounds. These are no different than recorded sounds. So, if you ever hear someone else throw up, are you going to avoid listening, or are you able to face the sound calmy because the sound itself is safe?
The next step: videos of people vomiting
So, we have worked both your visual and auditory cortex (the parts of the brain for images sounds) separately. Now lets work them both together.
To do this we are going
Again, listen to each one until bored and don’t use any safety behaviours.
The point is to test out two ideas:
Idea 1: ‘Reminders like sounds will lead to feeling nauseous, which will lead to you being sick’.
Idea 2: ‘You think that you will become panicked, out of control or unable to cope’.
Exposure videos
Woman retching and briefly throwing up off camera:
Woman vomiting. Vomit not seen:
Pre teen throwing up
Man vomiting a few times:
Woman throwing up on the ground
Scene from the comedy film bridesmaids. Contains scenes of food poisoning, diarrhoea and vomiting from multiple cast members:
Woman throwing up on the ground (f word used)
Teenager throwing up on the ground and laughing
Man making himself throw up
You did great!
Learning:
What have you learnt from watching those videos?
The whole point was to test out two ideas:
Idea 1: ‘Reminders like videos of people being sick will lead to feeling nauseous, which will lead to you being sick’.
You may have noticed you felt more nauseous or disgusted watching those. That is normal and the purpose of the disgust response. It is doing its job even though videos are not a threat as their is no chance of infection. But the real question again is, did those videos lead to vomiting? Most likely not.
Idea 2: ‘You think that you will become panicked, out of control or unable to cope’.
Did you feel anxious? Probably. But, what happened the longer you watched those videos? It should have got easier once you realised that watching these videos doesn’t lead to being sick.
Keep repeating this exercise until it doesn’t bother you any more.
Hopefully you learn that videos, even though they are unpleasant, are safe to watch. They have no ability to harm you. So they don’t have to be feared.
Now what?
It’s not good enough to just change our thinking about these types of cues. We need to change our actions in the future based on what we have learnt.
Based on what you have learnt, how are you going to react to videos in the future? Will this change how to handle films, social media posts or even how you might react to real people being sick?
If you notice you still avoid any other cues or reminders (conversations, smells, or places etc) face them using the same approach to test out if avoidance is necessary or not.
The next step: reassurance seeking
Okay we are finished with cues around vomiting. Hopefully, this has helped your Emetophobia. This is just one small piece of the puzzle to overcoming Emetophobia. There is still work to do. Let’s now move onto reducing reassurance seeking.
Ready for the next step?
Reducing reassurance seeking - click here
I specialise in treating Emetophobia, especially if cases where previous therapy has not worked. If you are exhausted from the constant battle against your phobia and its impact on your life, consider looking for 1:1 support.
Think you need 1:1 support to overcome your emetophobia?
Written by David Kaneria
CBT Therapist & Emetophobia Specialist
Author of Emetophobia: The Complete Guide for CBT Therapists