Fear of Vomiting

A common, chronic, early-onset condition that nobody has studied properly is an unusual combination, and it explains most of what follows.

Which diagnoses emetophobia gets mistaken for

Emetophobia is regularly misdiagnosed as obsessive-compulsive disorder, anorexia nervosa, social anxiety disorder or Agoraphobia. It can produce the presentation of each.

The obsessive-compulsive resemblance is close enough that Allen H. Weg lists the shared features directly:

• obsessional thinking
• hyper-awareness and reactivity
• avoidance
• compulsive rituals
• safety behaviours

The anorexia resemblance has the clearest test, and the 2015 reference states it plainly. A person with emetophobia may be severely underweight from restricting food, which looks like anorexia nervosa, and will not show the other features of it: no distorted body image and no fear of gaining weight. The restriction is avoidance of foods believed to carry a risk of sickness, and the weight loss is a side effect of the avoidance rather than its purpose.

The social and agoraphobic presentations follow from where vomiting might happen. Restaurants, alcohol, travel, amusement parks, crowds. The avoidance is identical from outside and the reason is different.

Why emetophobia's rituals target food safety

The behaviours listed are specific and consistent:

• checking expiry dates
• washing food repeatedly
• overcooking meat
• throwing food out before it expires
• refusing food prepared by other people
• maintaining a list of safe foods that narrows over time Reassurance-seeking is constant, and so is checking, both of other people and of the self, for signs of illness such as looking pale.

Over-the-counter nausea and stomach remedies are taken pre-emptively. Contact with young children is limited, which is a germ calculation rather than a dislike.

Why some women with emetophobia delay pregnancy

The survey by Joshua D. Lipsitz and colleagues produced the fact that shows the condition's reach most clearly. Women with emetophobia reported delaying pregnancy or avoiding it altogether because of the morning sickness of the first trimester, and those who did become pregnant found the pregnancy difficult.

A fear that alters whether somebody has children, on the basis of a symptom lasting a few months, is not a preference about food.

What is known about the cause of emetophobia

There is strong agreement that no specific cause has been established. Traumatic vomiting episodes are reported by many, always in childhood, and Lipsitz's respondents named severe bouts as children and witnessing others vomit through illness, pregnancy or alcoholism.

The most interesting proposal is testable and was tested. Angela L. Davidson and colleagues found that people with emetophobia are more likely to hold an internal locus of control, both in everyday life and in matters of health: a perception that outcomes are within their own control. Davidson's reading is that such a person finds it particularly difficult to relinquish control during an act that cannot be controlled, and that vomiting is precisely such an act.

That account explains the rituals better than a disgust account does. Checking, washing and overcooking are attempts to keep an uncontrollable event inside the domain of things a person can manage.

How cibophobia and emetophobia feed each other

The fear of vomiting frequently arrives with a fear of food, cibophobia, in which the worry is that food carries pathogens that will cause vomiting. Each supports the other: the food fear justifies the rituals and the rituals confirm that food is dangerous. Where the loop runs long enough, the presentation can arrive at something resembling anorexia nervosa, though the material is careful that obsessive-compulsive disorder may be the better description given how the symptoms are organised.

Avoidant and restrictive food intake disorder is also named as an overlapping diagnosis, since one of its defined routes is fear of adverse consequences from eating, vomiting and choking specifically.

Why emetophobia is harder to treat than other phobias

Two self-report tools exist, the Specific Phobia of Vomiting inventory and the Emetophobia Questionnaire, covering different ranges of symptoms.

Veale reported in 2009 that emetophobia is more difficult to treat than other specific phobias, and that the empirical evidence for cognitive behavioural therapy here is limited despite success in some cases. Exposure work is described with unusual concreteness: photographs of people who are unwell, confrontation with fake vomit made to resemble the appearance and odour of the real thing, and exposure to the physical sensations associated with vomiting, dizziness among them.

One finding from the survey deserves its own line. Asked whether they would consider anxiety medication, many respondents said they would not, for fear that the drugs would make them nauseated. The condition refuses its own treatment on its own terms.