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DEPRESSION AND ANXIETY 14:149–152 (2001)
EMETOPHOBIA: PRELIMINARY RESULTS OF
AN INTERNET SURVEY
Joshua D. Lipsitz, Ph.D.,1,2* Abby J. Fyer, M.D.,1,2 Anthea Paterniti, B.A.,1 and Donald F. Klein, M.D.1,2 Through electronic mail, we surveyed members of an internet support group
for emetophobia (fear of vomiting). Respondents were 50 women and 6 men
with a mean age of 31 years. Results suggest that, for this sample, emetophobia
is a disorder of early onset and chronic course, with highly persistent and intru-
sive symptoms. Emetophobia is implicated in social, home-marital, and occupa-
tional 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, so-
cial anxiety, compulsions, and frequent history of childhood separation
anxiety.
Depression and Anxiety 14:149–152, 2001. 2001 Wiley-Liss, Inc.
Key words: emetophobia; nausea; vomiting; phobia; anxiety; survey; Internet
INTRODUCTION
of a List Server mailgroup for individuals with emeto- phobia contacted one of the us (DFK) with the hope metophobia (fear of vomiting) has not been well of learning more about emetophobia. In response, we characterized. Marks [1987] emphasized concern over attempted to gather preliminary information about possible humiliation, suggesting that emetophobia this sample through a survey, distributed and returned should be classified as a social phobia. DSM-IV [APA, 1994] lists phobic avoidance of situations that maylead to vomiting as an example of specific phobia,other type. Lydiard and colleagues [1986] present a case of sudden onset of nausea and fear of vomiting as Based on responses to a series of open-ended ques- an example of panic disorder. Pollard and colleagues tions, we composed a survey of 29 items (survey avail- [1996] propose that the extensive avoidance caused by able from authors). We forwarded the survey to the fear of vomiting should be categorized as agoraphobia organizer of the List Server mailgroup for emeto- without panic. In children, authors have noted the phobia, who distributed it via email. From about 100 clinical overlap of this syndrome with separation anxi- active members, the host received 56 completed sur- ety disorder [Klonoff et al., 1984].
veys, which she then forwarded to us with no email Lelliot et al. [1991] compared a mixed group (n=71) addresses or other identifying information. Subgroups of patients with fears of vomiting or incontinence (fe- were contrasted using conventional t-tests for para- cal or urinary) with two other patient groups: one with metric variables and chi square tests for nominal vari- agoraphobia (with classic panic attacks) and one with ables. Probability values were computed based on social phobia. The vomiting/incontinence group was uncorrected two-sided tests with thresholds set at mostly female, had earliest onset, and was less anxious P=.05 for significance and P=.10 for noting statistical and depressed compared with the agoraphobia group.
Himle and Crystal [1991] included a small combinedgroup with vomiting or choking phobias (n=9) in com-parisons of modes of onset across phobia subtypes.
1Department of Therapeutics, New York State Psychiatric In-
They found that onset of phobia in this combined stitute, New York, New York
group frequently followed a direct experience with 2Department of Psychiatry, College of Physicians and Sur-
vomiting or choking. It is difficult to draw conclusions geons, Columbia University, New York, New York
from these mixed samples. A homogenous sample ofindividuals with emetophobia has yet to be studied *Correspondence to: Dr. Joshua Lipsitz, 1051 Riverside DriveUnit 69, New York, NY 10032.
The internet has become a valuable resource for conducting research into psychiatric disorders [Jerome Received for publication 7 October 2000; Accepted 23 January et al., 2000; Stones and Perry, 1997]. The coordinator 2001 WILEY-LISS, INC.
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Many respondents who were more fearful of vomitingin public also volunteered that they were fearful of PARTICIPANT CHARACTERISTICS
vomiting in private. Respondents who feared vomiting Respondents (n=56) were 89% female. They ranged in public were more likely to respond that they had in age from 14 to 59 years (mean=31.4; SD=9.7). Two problems with social anxiety (29% vs. 5%, χ2=4.71, were under 18. About half (46%) of the respondents were college graduates. All had graduated from high Panic attacks. Half the respondents (n=28) an-
school or obtained a GED, except for two who were swered yes to the question of whether they experi- still in high school. Thirty-four (61%) were working enced panic attacks that had “no relationship to outside of the home, ten (18%) were homemakers, (ongoing) fear of vomiting.” The most frequently seven (12%) were unemployed or on disability, four mentioned panic symptoms were nausea (82%), short- (7%) were full time students, and one was retired.
ness of breath (62%), and gastric distress (57%).
Thirty-one respondents (55%) were married or en- Comorbidity. Respondents described other mental
gaged, eighteen (32%) were single, and seven (12%) health problems they experienced in present or past.
were divorced or separated. We could not determine Since no clinical assessment was conducted, these re- country of residence, but use of language and descrip- ports reflect participants’ own understanding of their tions of context indicate that some did not reside in difficulties, which may or may not be based on diag- noses given by clinicians. Thirty percent said they werefearful of other specific things (e.g., insects) to which CLINICAL FEATURES
they react with disgust. Forty percent said they had Duration and persistence. Respondents portrayed
“panic disorder” or “agoraphobia;” 46% said they had emetophobia symptoms as early in onset, chronic in “depression;” 21% reported problems with social anxi- course, and high in persistence. Mean age of onset was ety, and 18% said they had “obsessive compulsive dis- 9.2 years (SD=5.0; range = 4–32 years of age). Mean order” (OCD). Fifty-seven percent (n=32) described duration at the time of the survey was 22 years (range past symptoms of childhood separation anxiety disor- = 2–54 years of age; SD=11.4). Twenty-nine respon- der (CSAD). With the exception of CSAD symptoms, dents (52%) denied having even brief periods of re- emetophobia typically preceded these other problems mission of symptoms. Twenty (36%) had partial or Treatment response. Nineteen (34%) respondents
brief remissions. Only seven (12%) described periods felt they had partial benefit from medications. Nine of full remissions of emetophobia symptoms lasting 6 (16%) benefited from psychotropic medications, which included benzodiazepines and antidepressants. Others Over 90% of respondents said they experienced dis- said they benefited from gastrointestinal medicines tress from emetophobia symptoms 52 weeks a year.
(e.g., Phenergan and Zantac). Many said they avoided Over 70% said they were distressed 6 to 7 days a trying medications for fear that these would make week. Some reported that distress lasted only a few them nauseous. Six respondents (11%) said they had minutes at a time, while for others distress was con- partial benefit from psychotherapy. A few patients stant (e.g., “nearly every waking moment”). Eighteen described having behavior therapy or hypnosis for (32%) said they felt distress during most of their wak- emetophobia with no benefit. A few individuals in psychotherapy for other reasons said they were too Self vs. others vomiting. Nearly two thirds of re-
ashamed or anxious to discuss emetophobia with their spondents (n=35) were more fearful of vomiting them- therapists. In general, respondents seemed skeptical selves than of seeing others vomit. Eighteen percent about the usefulness of psychotherapy. Only six said (n=10) said they were more fearful of seeing others they would be willing to try an exposure therapy that vomit. Twenty percent (n=11) said they were equally included exposure to vomiting sensations. Thirty (54%) said they would definitely not try this and Triggers. Almost all respondents said that feelings
twenty (36%) were unsure or said they would consider of fear were triggered by both external stimuli (e.g., sight of food) and internal sensations (e.g., acid stom- Impairment. Thirty-five respondents (62%) gave
ach). Mean percentage of time fear was triggered by examples of social impairment (e.g., avoiding parties external stimuli was highest (45.2%; SD=26.7), fol- where there might be alcohol). Nineteen (34%) gave lowed closely by internal sensations (40.5%; SD=26.3), examples of impairment in home-marital functioning with fear coming “out of the blue” seen as less com- (e.g., difficulty being left alone with young children).
Eleven (19.6%) gave examples of impairment in occu- Public vs. private. Nearly two thirds of respon-
pational functioning (e.g., having to leave work fre- dents (62%) said they were more worried about vom- quently for fear of vomiting). Five (9%) described iting in a public place. About a third (34%) said they impairment in school (e.g., skipping class). Seventy were equally anxious about vomiting in a public or percent (n=39) described significant constriction in lei- private place. Only two respondents (4%) said they sure activities. The most commonly avoided activities were more anxious about vomiting in a private place.
involved modes of travel (e.g., buses, airplanes, and car Brief Report: Emetophobia
151
trips) or venturing to new unfamiliar places. Twenty- in most clinical features. Respondents with unrelated two female respondents (44%) said they had avoided or attacks were more likely to say they avoided or had delayed becoming pregnant because of fear of vomit- problems with pregnancy (96% vs. 62%; χ2= 8.8; ing; 12 others (24%) said they feared pregnancy for P<.005) and to report problems with depression (61% this reason but this had not affected their plans. Six vs. 32%; χ2=4.6; P=.03). There was a trend for those other women (12%) said that emetophobia had made with spontaneous panic attacks to less frequently re- their pregnancies especially distressing.
port direct vivid vomiting experiences that preceded Three quarters of the respondents (n=42) said they emetophobia (7% vs. 25%; χ2=3.3; P=.07).
had rituals around eating (e.g., excessive washing or re-peated checking for freshness) or had significantly lim- DISCUSSION
ited the way they eat or the type of foods they eat.
Many volunteered that they do not eat outside of the Results of this survey suggest that for some indi- home or eat only from a list of “safe foods.” A few re- viduals emetophobia is a chronic, pervasive, and de- spondents expressed concerns about having poor nutri- bilitating disorder. Emetophobia may cause daily tion and being underweight because they were too distress, effect social, home, and marital functioning, worried about what they eat. Twenty-four respondents and lead to avoidance of pregnancy. Severity of anxiety (43%) said they avoided using the word vomit for fear and impairment in our sample seems to be more se- that this would trigger images or sensations of vomit- vere than in the combined sample (with emetophobia ing. In correspondence in this support group, individu- and incontinence concerns) of Lelliot and colleagues als typically use the letter “v” to refer to vomiting.
[1991]. However, since current findings are based onan anonymous survey in a convenience sample, we ETIOLOGIC FACTORS
hesitate to draw conclusions. Our main goal was to ef- Conditioning experiences. Sixteen respondents
ficiently gather data that could inform future studies.
(29%) recalled having severe or vivid bouts of vomit- Unfortunately, little is known about the prevalence ing, although in four of these cases fear of vomiting of emetophobia. Case reports [e.g., Phillips, 1985] are reportedly preceded the vomiting experience. Thirty- rare. An unpublished report [Kirkpatrick and Berg, three respondents (59%) recalled vivid experiences in 1981] found fear of vomiting to be at the “extreme or which they witnessed others’ vomiting. In some cases terror” level in 3% of men and 6% of women in a these were repeated exposures to relatives, including non-psychiatric sample. However, it is not clear how parents, who were ill, pregnant, or alcoholic. Eleven many of those people might have significant distress respondents (20%) had distressing experiences both of vomiting on their own and of observing others.
The early age of onset and chronic course of emeto- Medical history. Eleven respondents (20%) had
phobia are consistent with the DSM-IV categorization been hospitalized overnight in childhood. Seven of of specific phobia. Although many specific phobias are those (above) who recalled vomiting experiences had more clearly focused on external stimuli, internal fo- also been hospitalized and vomited from illness or in cus of fear (e.g., fear of panic attacks) is common in response to medical procedures (e.g., anesthesia).
some situational and blood injury phobias. In descrip- Others were hospitalized for common childhood tions of fear, most respondents emphasized the discom- problems (tonsillectomy and broken leg) with no clear fort of vomiting rather than fear of embarrassment connection to vomiting. About 30% of respondents and many were as anxious about vomiting in private.
said they had experienced a serious medical problem Thus humiliation seemed to be a frequent, but sec- in adulthood, the most common which were endo- ondary, concern as is often the case in panic disorder.
crine disorders (n=4), gastrointestinal disorders (n=3), These preliminary data do not support the categoriza- tion of emetophobia as social phobia by Marks [1987], Family history. Excluding two respondents who
although a thorough diagnostic study is needed to were adopted, 57% (n=31) said at least one first-de- gree relative had been diagnosed with a psychiatric Persistence of fear in absence of clear external trig- disorder. The most common disorders reported in gers, along with avoidance of numerous situations (e.g., relatives were panic disorder (n=11), depression (n=9), travel) loosely related to the feared event, suggest a and OCD (n=5). Four respondents (7%) said that first clinical picture more consistent with agoraphobia. A difference is that avoidance in agoraphobia relates tofear of incapacitation should, e.g., a panic attack occur.
PARTICIPANTS WITH AND WITHOUT
In the current sample fear is of the occurrence of a nox- PANIC ATTACKS.
ious event. Individuals avoid numerous situations for In an effort to clarify the relationship of this syn- fear that they might encounter a trigger for nausea or drome with panic disorder, we compared respondents vomiting. Interestingly, more than a third of respon- who reported having panic attacks unrelated to emeto- dents say they fear seeing others vomit as much as vom- phobia with those who denied unrelated attacks. No iting themselves. No such fear has been reported differences were found in participant characteristics or among agoraphobic patients with panic attacks.
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Although half of respondents said they had sudden ciency. Further research is needed to determine the re- onset panic attacks, we could not confirm that these liability of information obtained anonymously through were full symptom panic attacks nor could we deter- the internet [Childress and Asamen, 1998]. From a mine their relationship to emetophobia. Reported dif- clinical standpoint, this support group appeared to play ficulties with “panic disorder” or “agoraphobia” may an important role for many of its members. For those be independent of emetophobia symptoms or may with an unusual disorder or a disorder that is rarely have been (mis) diagnosed based solely on emeto- talked about, the anonymity and geographical breadth phobic avoidance. The relationship between panic at- of the internet may present the only opportunity to tacks and emetophobia would also be better studied share information and support with others who have using a thorough diagnostic assessment with special attention to sequence of symptoms and focus of fear.
Responses also highlight the compulsive quality of some behaviors related to emetophobia. Many respon- REFERENCES
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Source: http://www.emetofobie.nl/emetofobie.pdf