Disclaimer: This is an article about getting sick, particularly nausea and vomiting. If you are squeamish or anxious about this, reading this article may cause distress.
In 2004 the Elementary School my daughter attended had an outbreak of the flu. She saw several kids vomit. She became afraid of getting sick. I have since discovered she was not alone. Over the years it has been my professional experience and personal opinion that the fear of throwing up or getting sick (nausea & vomiting) is far more common than reported in the professional literature and media. It is often missed as the core fear with anxious children. If we get calls from families who have used Turnaround yet still need some extra help it is almost always about this particular fear. It tends to impact school attendance, eating behavior and social interaction in such a way it cannot be ignored or accommodated.
This fear is called emetophobia. Emesis is the Greek word for the act of vomiting. Phobia, from the Greek phobos, is an intense inflated fear. This phobia is a problem for adults and kids. I see both frequently.
Dr. McCarthy and I have completed a supplemental program that is now available.
Importance of Understanding HOW a Phobia Develops and Continues
It is necessary to understand “how” the fear works. If the “how” makes sense, the treatment makes sense. Most of the time people want to know “why” there is the fear but that isn’t nearly as helpful as understanding “how”. Let’s begin with a general explanation that would fit most sorts of anxiety but focused on emetophobia. I am going to use a series of diagrams to explain the reinforcing cycle of this phobia**.
Step 1: A Trigger
First there is something that “triggers” or signals a threat to a person. It can be external as in seeing someone throw up or internal as in imagining someone throwing up. It could be external like a disgusting smell or internal as a gagging feeling. Any of the senses; sight, smell, taste, hearing and touch, could be involved in triggering the fear.
A trigger isn’t inherently something bad. It is just information. Two people can experience the exact same trigger but one person is fine and the other gets alarmed. It is the next steps that give meaning to the trigger that make it part of an anxiety cycle.
Step 2: Misinterpretation
In the case of a phobia the trigger is misinterpreted as far more threatening than it really is. For example, throwing up is viewed not as unpleasant but as catastrophic. This threat seems so real or possible to the person because of how they mentally construct it.
There is an important point to be made here. Fear of actual danger is not a problem needing treatment. No one gets therapy because they ran in the house after lightning stuck nearby. They get treatment because they get extremely anxious when there are just dark clouds so much so that it interferes with their lives.
Human beings are designed to learn fear FAST and to extend the sense of threat to anything similar or related. I only have to step on a nail once to forever be careful walking through construction debris. This is a good thing. There is a solid logic to being scared by a nearby lightning bolt and then be on the lookout for future lightning bolts.
However, a problem is beginning when the fear spreads to things associated to the specific threat that are imagined as far more dangerous than they are in reality. They key word is imagined. It is a mental movie about something that might happen. For example, lightening is obviously dangerous but storm clouds are not that dangerous. When someone is phobic the dark clouds become a mental movie of lightening striking and killing, therefore the dark clouds = lethal danger. In the case of emetophobia vomiting is misinterpreted as a threat. (Sometimes, embarrassment of vomiting in public is more of the imagined threat.) Then the mind spreads it to anything that might lead to vomiting like an uncomfortable feeling in the tummy or the “contaminated” desk of someone who got sick.
This is still all normal. We misinterpret things all the time. Everyone imagines distressing things like this but it only occasionally leads to a phobia. There are more steps involved before it becomes a phobia.
Step 3: Anxiety, Fear or Worry
So there is a trigger, then misinterpretation, and then intense anxiety. Although the imagined danger is not real, the experience of anxiety is real. That makes the misinterpretation seem much more plausible. When a threat is perceived the body prepares – dramatically.
This process is often called the fight or flight response. Without going into too much detail, it is the body’s way of responding to danger – real or imagined. In the right circumstances this process instantly optimizes your body to survive. In the wrong circumstances it can become part of an anxiety disorder. Panic while running from a charging rhinoceros is good. Panic while sitting in a classroom, not so much. It is basically the same physiology but interpreted differently.
Anxiety disorders are fundamentally incongruence between what a person is thinking and feeling compared to the actual situation. Using our previous example, the anxiety for an actual lightening strike is evoked by dark clouds. The physical reaction is just as strong for the imagined problem as for the actual danger. For emetophobia there is extreme distress at the possibility of vomiting. The anxiety leaps to anything that might lead to vomiting. (In one of life’s great ironies, anxiety causes stomach distress and then that evokes more anxiety.) The belief that it is a serious threat leads to the next step. This is the tipping point of something becoming a phobia.
Step 4: Avoidant Coping
This step may be the key element in why someone develops an anxiety disorder. Everyone experiences the first 3 things but not everyone develops an anxiety disorder. The tipping point is when someone acts consistently with the misinterpretation. In other words, they behave as if the imagined fear is truly a threat. The main thing people do is avoid or escape the “danger” in a desperate attempt to get relief. When you are terrified, relief is AWESOME. People come back for awesome over and over. Then it becomes a powerful habit and even a compulsion. Because it does give relief it is very hard NOT to do it. Unfortunately, these kinds of behaviors interfere with living a normal life. At first it might not be that disruptive. But it gets bigger. For example, if you are afraid of getting sick first you may want to avoid a classroom but then you will want to avoid school. Getting to stay home gives relief. We all know how big a problem that becomes. Less dramatically, if the fear is contamination causing illness there could be extreme hand washing and cleaning. The urge to escape, avoid or fix can become ferocious. If you have tried to stop a terrified child from doing something to avoid the fear you know what I mean.
Let me state again that avoiding authentic, genuine, and certified danger is NOT a problem. (Well, okay it is big problem but not regarding anxiety disorders.) Anxiety problems only happen when there is not an actual threat. Because the anxiety “feels” real and the avoiding “feels” better this becomes enormously influential. Because this becomes the norm, the next step seals the deal.
Step 5: No Correction
When you avoid, escape or fix you don’t experience the things necessary to disprove the threat. Your misinterpretation doesn’t get corrected. In fact, over time you add more and more “proof” that it is really perilous. Not concrete or accurate evidence just more imagined proof. For example, if a child is afraid of vomiting she might begin to hyper-focus on how her stomach is feeling. What is going on in your stomach changes continually. At any given point in a day a person will likely feel some discomfort in his or her stomach. This normal discomfort is misinterpreted as increased likelihood of vomiting and is avoided if possible. She might change her eating habits if she thinks the feeling is connected to a certain food. That food is now additional “proof” of how likely she is to vomit. Stressful things cause stomach distress at times and so stressful things are avoided. Each additional association becomes more false evidence of threat.
Because she is now worried most of the time, she will scan for evidence of threat and gradually “discovers” more and more potential dangers and the cycle continues. The triggers remain triggers because they are never challenged and repetition strengthens the cycle. More triggers are added and they become part of the cycle.
An Example of the Cycle
Okay, let’s drop a simple example into this cycle. Here is something that seems quite ironic to me. Lot’s of kids are scared of clowns. They are supposed to be funny and likeable right? Anyway, imagine a young boy, Ben, at a circus. He is captivated by all the sights and sounds and doesn’t notice that a clown comes up behind the audience and does something noisy (which is what clowns do). (1. Trigger) The clown startles Ben with the loud noise, he turns and sees this wildly dressed “thing” (2. View as Threat) and he starts to cry (3. Anxiety). Ben turns away, buries his head in father’s chest and is so upset the family leaves (4. Avoidant Coping & 5. No Correction). After a few days, no one thinks much about it but a clown comes on TV. Ben, to everyone’s surprise, gets anxious and cries (1, 2, and 3). What happens next? The channel gets changed or Ben leaves the room (4 & 5 again). Clown triggers are pretty easy to avoid so to keep the peace the family makes sure no clowns are around (4 & 5 again). No one else in the family thinks clowns are scary but they don’t want to freak out Ben so they inadvertently add proof that clowns are dangerous by helping him avoid them. But then he goes to a friend’s house and there is a clown doll. It is close enough to the real clown so now clown dolls are scary and another trigger is added. The clown doll is avoided or removed. (1, 2, 3, 4, & 5). The cycle is reinforced and becomes more elaborate. Sometimes it jumps to any costumed characters – more triggers. It just has to be similar to the existing fear to become part of the cycle.
The Cycle for Emetophobia
So how does it work with emetophobia? No one likes to feel nauseated and sick. Vomiting is awful. Vomiting is NOT dangerous or threatening however. I’ll use the example of my daughter. One of my pet names for her is Lelu. Lelu is at school and sees several students get miserably sick and vomit. She sees, hears and smells it. (Step 1). Lots of kids are getting sick. She naturally thinks she could get sick. But she thinks it would be terrible physically and humiliating. She interprets it as far worse than it is (Step 2). She begins to fear getting sick (Step 3). She wants to stay home while the flu is going through the school (Step 4). I think we may have let her do that (can’t remember for sure) at first (we reinforced Step 4). She avoids anyone who might be sick. She avoids anything that might be contaminated with flu virus (Step 4 & 5). She starts to ask us if she is sick. She wants us to check her temperature. She wants reassurance she isn’t sick. We do that (Step 5). She washes her hands. We tell her she is fine but start to make accommodations so she won’t freak out (Step 4 & 5). The reason reassurance doesn’t fully work is because kids know you can’t promise they won’t get sick. No one knows. But it helps a little so they keep asking. We stop saying vomit or synonyms, we change the channel (there is a surprising amount of vomiting on TV, even kids shows), she scans her body to see how she is feeling, especially her stomach. Well, anxiety causes digestive distress. (Step 1, 2, 3, 4 & 5).
Explaining It to Your Child
So, one of the first things to do in treatment is to explain how this fear of throwing up works to a child. Someone afraid of this is seriously worried about vomiting. Explaining how anxiety works makes it less scary. Understanding gives a bit of control. It will also make the treatment make sense. First we suggest you use the cycle to explain something unrelated. Think of a time your child was a bit scared to do something new like ride a bike, swim in the deep end of the pool, go to camp, etc. Make sure it is something they are no longer afraid of and show how they went through the process.
Here is an example. Annie, remember when you learned to ride your bike? We took off the training wheels (step 1) and you were nervous you might fall (step 2). You were really upset and worried (Step 3). You went into the house and refused to get on the bike at first (on the edge of step 4). But you let your dad hold you in the seat. He held you at first as you started to ride until all of a sudden you said, “Dad, let go,” and off you went. The cycle stopped because you didn’t do step 4. You faced the fear and realized it wasn’t that dangerous to ride a bike and so Step 5 didn’t happen because you had evidence it was safe enough.
**Functional analysis based on lecture notes from Pollard, A. C. (2012) Cognitive Behavioral Treatment of OCD. Behavior Therapy Training Institute. Massachusetts General Hospital, Boston, MA
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