Free yourself from emetophobia: Veale
Contents
Chapter 1 What is Emetophobia 1
Chapter 2 What keeps emetophobia going 3
Chapter 3 Cognitive Behaviour Therapy 6
Chapter 4 Defining your problems and goals 7
Chapter 5 Actively defeating your Emetophobia 7
Chapter 6 Understanding and dealing with common obstacles 10
Chapter 7 Bringing it all together 12
Chapter 8 Medical treatments for emetophobia 12
Chapter 9 Considering your support network 13
Chapter 10 Advice for friends families and partners 13
Chapter 1 What is Emetophobia
Generally a fear of self being sick, occasionally purely
other (rather than other infects me and I am sick)
Images
Can have intrusive images, flashback, to that awful time, or
flashforward to that awful time.
The images
will be of disgust of other judgement, of lack of control
Fear
Of
uncertainty, will I or wont I get it
Physical
There is
often an accompanied nausea , uncomfortable feelings in the stomach what accompany
a fear of being sick.
Emotions
Anxiety
Thoughts
That it will
go on for ever
That others
will find me repulsive if I’m sick
Attention
Self focused
Behaviours
Avoidance of threats: food poisoning, ill people. Both are
checked and restricted
Feeling sick and vomiting are difficult to avoid at some
point it will happen.
90% of sufferers are women.
Men may feel more shame to admit it, women are more hygienic, more
sensitive to being revolting and more likely to develop contamination fears in
OCD.
OCD a problem with uncertainty if someone will vomit is on
the continuum up to emetophobia
There is often repetitive behaviour to prevent being sick
Check sell by dates
Cooking excessively
Check if people are sick
Not sit close to people
Excessive hand washing
Comorbidity
OCD and emetophobia on a spectrum around fear of
contamination
Emetophobia and social anxiety 10-20% comorbid, fear of
being judged as revolting
Emetophobia and health anxiety: strong similarities, worry
about sickness, avoidance sick triggers, body checking, only difference one is
a fear of serious illness the other a fear of vomit
Emetophobia and panic attacks, people can experience panic
attacks when they fear they will vomit
Chapter 2 What keeps emetophobia going
Old Brain: reptilian: threat\drive system: triune brain
Emetophobia
Threat system over engaged
Drive system as a defence: keep busy
Threat of emetophobia made by the new brain, enacted by the
old brain, as the threat and drive system, go into service of the new brain.
Whilst the threat starts with the new brain, gets the old brain involved, then
the new brain, cant turn off the old brain but rationalising.
The emotions that play a part of emetophobia are anxiety,
through the fear of becoming sick. Disgust at the act of being sick. Emetophobics
have stronger and more sensitive producers of disgust experiences. Disgust
may also be associated with a sign of danger.
Anger is involved at the person who might threaten sickness on you, but
that person could be yourself. Anger can also be at yourself for not doing
something you wanted to do because of emetophobia.
Early life experiences.
People might have vomited, and believed\were they were
abandoned, shamed, harshly judged, laughed at,
and the associate vomiting with that.
There might be the ideas that they were seen as disgusting and not the
vomit, i.e. their behaviour. When they vomited they might have experienced it
as violent, and them as out of control, they might not have been comforted,
rather shamed.
Environmental factors
Seeing a loved one vomit then becoming seriously ill.
Abuse at the time of the vomiting episode
Over protective parents : their implied awfulness of vomiting.
Being physically vulnerable and catching a vomiting bug
Personality factors
Emetophobics have a strong sense of internal control, that
they can control what happens to them
Physical factors
Higher levels of somatization, i.e. expressing emotions
physical
What maintains emetophobia
Expectancy of vomiting, through thoughts, and physical
feelings.
Judging vomiting as being 10% awful
Vicious cycle
Anxious thoughts about vomiting
Anxiety
Somatised into physical feelings
Increases fear that I will be sick
Short term payoff long term problem
Worrying\reassurance seeking: (however they focus on the
problem reinforce how awful it is, and increase its perceived likelihood)
Self focussed attention and looking for danger: again
stimulate feeling sin the body, increase the sense of the awfulness of it, Increases belief that you can control
vomiting, but when you need to vomit you cant stop it, and that’s a good thing!
Avoidance: maintains the belief in the awfulness, shrinks
your world, and leads you to not learn how to manage situation, or indeed to
find out you can manage a lot better than you think. Avoidance maintains
anxiety as the next time you face the situation you feel anxious and have to
avoid it.
Safety seeking and compulsive behaviours e.g. checking sell
by, over cooking, handwashing. Here every time we do them, we are reminding
ourselves how awful vomit is, that we can protect ourselves against it and that
actually we will be safe if we don’t do them (self perpetuating)
The awfulness of vomiting also increases with the levels of
effort you put into stopping it (paradoxically)
Chapter 3 Cognitive Behaviour Therapy
Emetophobia: peoples anxiety is somatised, they scan their bodies and believe their body
sensations are a sign that they will
vomit, they will lose control and it will be truly awful. This relates
to safety seeking behaviours and avoidance.
Psychoeducation:
A reflex for humans, when our body thinks it has ingested a
toxin. Rats don’t vomit, that’s why rat
poison works so well. You stop vomiting
when there’s nothing in the stomach, vomiting might be horrible but it has a
distinct start and end.
Theory A: You are at risk of vomiting any time. Vomiting is
awful, you will lose control and it and your anxiety will go on for ever, a fate worse than death, and you cannot bear
it. You must engage in SSBs, and avoid many things.
(This is an anxiety problem and gets maintained with the
vicious flower)
Theory B: Vomiting is unpleasant, useful and you can bear it.
This is a problem of vomit, and we will assume it is true. The problem you have is because you are trying
to not vomit!
(This is a pathogen
and biology problem)
With Theory A\B we can use behavioural experiments to test
if its more A, does the problem get worse with changes in emotions for
instance.
Erp: Graded exposure key to emetophobia, to learn that
avoidance and safety behaviours aren’t needed, so reduces the maintenance of
the fear
Image rescripting:
Rescript, rebuild and loving eyes;
Chapter 4 Defining your problems and goals
Rate severity of emetophobia
Define the problem by rating varies domains of your life and
how much emetophobia gets in the way of it.
Set SMART goals
Chapter 5 Actively defeating your Emetophobia
The length of the problem, the more effort you will need to
put into it. Testing predictions, ERP and drop safety behaviours. More effort you put in at the beginning the
greater your momentum.
With emetophobia the aim is to tolerate its related anxiety
and disgust, so that you can act in ways that are important to you and not to
manage your anxiety and disgust. Whilst it is important to face you fears and
to learn that they are disproportionate, having techniques to manage anxiety
can help if the emotions are very strong.
Techniques to tolerate anxiety
1.
Slow breathing
a.
Make sure your outbreath is 2 beats longer than
your in breath. Breathe into the belly
2.
Connect with others\and the world: there is a
tendency to have self focussed attention which enhances the anxiety, really
look at a plant, bird, person, talk to them, listen to them. Get some emotional support for what you are
doing is hard, not rather getting reassurance that you wont be sick
3.
Cold water
a.
Put your face in cold water, which stimulates
your parasympathetic nervous system
4.
Grounding technique
a.
5:1
ERP
Face a manageable level of fear of something that is
important to you.
Learn you can tolerate the anxiety.
Let the anxiety\your body learn there is nothing scary in
this situation (the only scary thing is the anxiety!)
Anxiety isn’t pleasant but it isn’t going to harm you.
Anxiety and disgust help you prepare for a threat, but what
if there isn’t a threat, what if it is a false alarm.
For every step on the graded hierarchy it is important to
stay with the anxiety until it has reduced by at least half.
Jumping around the hierarchy is more effective than a linear
approach.
Chaining exposure tasks can be powerful, so eat a food you
might avoid in a busy public place, then read in the car on the way home.
Practice once a day, to build up momentum.
During your exposure act as if theory b is true.
Notice subtle SSBs
whilst doing exposure, mental reassurance, small sips of water.
Be compassionate to yourself, speak in soothing tones, to
encourage yourself to do something difficult.
Behavioural experiments
Drop SSBs and see what the effect is: Test theory A.
Person fake vomits in public: see what happens
Eat food you have avoided: see what happens
Don’t over cook: see what happens
So Theory A: it could happen any time, it would be awful you
need to protect yourself, and we can understand this via a vicious flower, and
that it’s a problem of anxiety
Theory B, its a vomit
problem, its unpleasant, it will happen, you can bear it.
Image/Memory work
Change the image
Different characters, different form, don’t end at the worst
point.
Most images problems end at the worst point!!
Rescript the image: Relive, rescript and loving eyes.
Changing your thinking
Change your relationship with your thoughts via mindfulness.
Reassurance seeking
Key distinction between assurance which is a one off that
things will be ok, to reassurance, repeated questioning that things will be ok.
Working with attention
Our attention goes to our body and “abnormal” sensations, or
threats in our environment. We are laser focussed on the problem and its
solutions, so we need to widen our attention to positive, neutral and negative
things that are not related to vomit.
Learn when you are not anxious, use when you are:
Pick a sense, I’ve used sound
1.
Sound attention: notice sounds, close, near, far
away. Listen mindfully.
2.
Switch attention between them. Spend a minute on
each one
3.
Practice and when mastered then use it when
anxious to switch your attention to something less threatening
Working with Worry
Worry isn’t like problem solving, its about things outside
of our control, its about getting a sense of certainty over something (even
though you cant be).
Monitor your worries and classify them
Have they happened, can you control them?
If you cant do anything about it, then commit to something
different, if you can do something about it then do it. Best doing something
different is something that you value that takes up mental energy. You could do
something about vomit, if I vomit then, which would be vomit safety plan. When
I vomit, what would be nice is, this would be as opposed to avoiding vomit at
all cost.
Chapter 6 Understanding and dealing with common
obstacles
Trying too hard to be perfect
Don’t achieve, so stop
Putting effort into the right\best therapist\approach\understanding
etc, slows you down.
Rather just start, and try to improve things for yourself,
with good enough.
Fear of making things worse
You will fear dropping your SSBs will make things worse and
you will vomit, but
Emetophobics and non Emetophobics have the same rates of
vomiting.
Fear of looking back and regretting change
You feel comfortable where you are, known is better than
unknown. Remind yourself of why you are doing this. Think of your eulogy would you want it
contain lived a life protecting yourself from vomit?
Wanting coping techniques and mechanisms
This would just be new SSBs and leave the belief in place
that vomit is awful and I must control it. CBT aims to get you to say vomiting is
possible, rare, but possible. Unpleasant but tolerable.
Shame and self criticism
Shame can prevent opening up about your difficulties. You
might have shame about your initial vomit incident, shame about your emetophobia,
shame about difficulties in dealing with it, layers of shame.
Intolerance of discomfort
In ERP you are building up your distress tolerance amongst
other things. Mindfulness can help
Not enough time
Evaluate available time, can you save some time, is now the
right time?
Insufficient dose of deliberate practice
Don’t leave too longer gap between ERPs as you want to build
up momentum, like bicycling down a hill, like taking a plaster off its easier
just to do it, not to think about it, or try to do it slowly.
Chapter 7 Bringing it all together
Monitor your progress and build evidence for Theory B
Rate your goal progress
Consolidate what you’ve learnt, in terms of maintenance cycle
and techniques
Managing lapses, relapse prevention. What do you need to
keep doing to stay healthy?
Early warning signs of lapse, and response.
Chapter 8 Medical treatments for emetophobia
There is anti nausea medication, but emetophobics nausea is
caused by anxiety. Anti nausea drugs don’t
stop you being sick.
SSRI
Possibly after CBT for severe emetophobia\OCD. Effects start
at 4 weeks, and it can take up to 16 weeks to see the full effect. Stay on it for 12 weeks before deciding if it
does\doesn’t work.
The worst side effects are at the start and they reduce,
although not sexual difficulties. Side
effects more likely with a big increase in dose.
Side effects
Short term
Diarrhoea/Constipation
Nausea
Headaches
Sweating
Dry mouth
Tremor
Sleepiness
Emotional numbness
Sexual problems: cant orgasm, lose libido
Loss of appetite
Agitation
Chapter 9 Considering your support network
Can be helpful to have a support network when doing
something hard like this, to encourage and comfort, to celebrate, all of which
will help you to progress.
However, people can misunderstand your problems, which can
leave you feeling isolated.
But you can explain your thoughts and feelings and the
impact it has let them know it’s the most
common specific phobia in UK
Friends and family
They may be difficult to use as a support network as
They may make judgements about you, gossip about you, you
may worry about them being a burden, they , may minimize your problems, you may
feel shame.
Emotional support is different from reassurance seeking. Emotional
support is when you are having a hard time, is validating, encouraging,
listening and the like. Reassurance is when someone tells you repeatedly that
you aren’t going to vomit\panic etc.
Whilst it might be scary to do, opening up to the right
friends and family can be very powerful to get emotional support (and not reassurance).
Equality act, says workplaces cant treat you differently due
to your mental health, if it affects your long term ability to perform your
duties, so it cant discriminate, so adaption needs to be made. Employers cant ask about your mental health
before offering you a job. Employers must prevent you being harassed.
Chapter 10 Advice for friends families and partners
Supporting a person with emetophobia is about supporting,
encouraging, helping them manage their distress, championing them and celebrating
their successes. They need to face their fears to find out they are ungrounded,
what keeps their problem going is avoiding their fears. They need to be able to
see their anxiety is tolerable and is not indicative of something bad
happening.
Agree with them what would be helpful from you, and how.
Children with emetophobia as they are less able to label
emotions, will typically report physical problems.
