When treating anxiety or OCD, the first step is answering the question of "What exactly is it the client is afraid of?”

Emetophobia is the intense fear of vomiting. People with emetophobia may go to great lengths to avoid situations where they think they might vomit or see someone else vomit.

As with OCD, emetophobia symptoms can be debilitating and affect the client’s quality of life in various ways.

 • Typically, people with emetophobia are only able to eat a few “safe” foods, and the patterns of avoidance may not make sense to the casual observer. For instance, an emetophobic may avoid bread products due to a fear of mold, yet may be perfectly fine eating fried, fatty foods, which most people would think of as more likely to lead to nausea or vomiting.

 • Consumption of other things may also be avoided, such as alcohol or over-the-counter and prescription medications, the latter of which often have written right on the label that nausea may be a possible side effect.

 • Emetophobics may avoid eating too quickly or eating later in the day, and food intake of any kind, including water, may be restricted to the home to avoid the possibility of vomiting in public.

 • Adults with emetophobia may avoid social venues, such as bars or parties, where they expect significant amounts of alcohol will be consumed.

 • An individual with emetophobia’s work may suffer because they avoid travel, work-related social activities, or the employee cafeteria.

 • There may be hyper-vigilance and hyper-reactivity in response to a person burping, coughing, looking pale, or even people placing their hand on their stomach.

Emetophobia is often diagnosed as a Specific Phobia. However, because the most prominent symptoms often meet the criteria for obsessive compulsive disorder, OCD may be the more appropriate diagnosis. 

The task of the clinician is to ultimately trace the client’s symptoms to the fear of vomiting. As with other forms of OCD, once identified as a case of emetophobia, exposure and response prevention (ERP) can be applied as the core treatment.

In emetophobia treatment, ERP is best applied to three different areas of the emetophobic symptoms:

 1. Physiological Symptoms: The first area is the physiological symptoms associated with nausea and vomiting itself, which trigger anxiety. To address the physiological symptoms, we would have the client engage in interoceptive cue exposure (sometimes called symptom cue exposure). In this treatment, the client purposely creates physical symptoms associated with nausea and vomiting by engaging in certain self-controlled exercises. These exercises may vary, but can include things like spinning in place or hyperventilation, both of which can cause nausea, dizziness, and light-headedness.

 2. Environmental Triggers: A second area is the environmental triggers of emetophobic anxiety. Targeting the environment triggers may include going places that have been avoided such as bars, lunchrooms, or public bathrooms. ERP is conducted exactly as one would do for OCD avoidance behaviors, where a hierarchy is established and followed, and the client moves up that hierarchy as anxiety is better managed. Another environmental exposure focus involves exposure to the avoided foods themselves, and is treated similarly through ERP therapy. Once well tolerated, these above exposure experiences may be combined during treatment. For example, a person could hyperventilate creating feelings of nausea and then immediately eat a certain food that had previously been avoided, all while in an environment that had previously been avoided, such as in a restaurant.

 3. Simulated Vomiting: A final area of treatment involves exposure to the act of vomiting itself. I do not recommend having the emetophobic vomit, because I do not think it necessary for recovery. Instead, therapy involves having the emetophobic engage in simulated vomiting. In this case, replicating an exposure to represent vomit (e.g., canned beans mixed with corn and peas). The person stands or kneels in front of the toilet with the seat up, takes a mouthful of the bean mixture in his mouth, and spits it into the toilet repeatedly, flushing afterwards each time. Just as important as the method above, exposure to vomiting itself can be done by finding videos on the internet that show people vomiting (e.g., www.EmetophobiaResource.org).

Emetophobic's reading this may be shocked and even frightened off at what I am suggesting. Exposure to our fears sounds terrible, but believe it or not, ERP, including interoceptive exposure, environmental exposure, and simulated vomiting exposure has helped people with emetophobia to move forward in confronting fears, and lead to greater freedom and lowered anxiety. (Read my blog on What is Exposure and Response Prevention (ERP) and will ERP work for me?)

In my experience, when a motivated and disciplined client is engaged, this combination of interventions can result in substantial improvement and often a complete elimination of symptoms.

Written by Eliyahu Serkez 

The Anxiety & OCD Therapy Practice