Emetophobia: A fear of vomiting.

Emetophobia is an intense, irrational fear of vomiting including fear of feeling nausea, seeing or hearing another person vomit, or seeing vomitus itself. It may occur at any age and we need to understand its symptomatology. We report a case of emetophobic child whose fear of vomiting started after an attack of acute appendicitis. In the initial stage, fear was limited to vomiting, later it became generalized to a fear of seeing the vomitus, worries that parents may suffer vomiting, fear of vomiting in public places followed by avoiding social activities. Patient improved on short course of anti-anxiety drugs and Graded Exposure Therapy.

INTRODUCTION

A phobia is defined as an irrational fear that produces a conscious avoidance of the feared subject, activity or situation and the presence or anticipation of it elicits severe distress in an affected individual.[1] There are various types of specific phobias including acrophobia, claustrophobia, zoophobia, etc., Specific phobia of vomiting, also known as emetophobia, is relatively understudied with respect to its etiology, clinical features, and treatment.[2] It is a specific phobia (other type) according to the current edition of the Diagnostic and Statistical Manual of Mental Disorders.[1] This specific phobia can include a fear of vomiting in public, a fear of seeing vomitus, a fear of watching the action of vomiting or fear of being nauseated. Emetophobic symptoms can be mental, emotional, and physical. The anxiety and fear can go from mild feelings of apprehension to a full-blown panic attack. Emetophobia is implicated in social, educational, and occupational impairment and it causes significant restrictions in leisure activities.[3] There is no available data on the prevalence in the general population and little is known about the etiology. Most studies describe predominance in females, early (childhood) onset and chronic course. The most important differential diagnoses are: Panic disorder with agoraphobia, social phobia, anorexia nervosa and obsessive-compulsive disorder.[4] An emetophobic child may be nonresponsive to conventional systematic desensitization therapy.[5]

CASE REPORT

An 8-year-old girl, studying in second grade was brought by parents with complaints of fear of vomiting and feeling nauseated since about seven and half months. Around 20 days before the starting of symptoms, child had episode of acute and severe abdominal pain, high grade fever with 3 bouts of vomiting with nausea for a day. She was diagnosed as having acute appendicitis by a surgeon and was operated subsequently. Within around 10 days after operation, patient started having fear of similar episode of vomiting with repeated remembrance of the episode. She complained of feeling nauseated with excessive salivation and gastric regurgitation. The treating doctor did not find anything significant and was treated symptomatically. Parents were reassured about the symptoms. She started attending her classes but gradually her complaints increased. She had constant thoughts of feeling nauseated. She started eating less, avoiding outside food which she used to ask for previously. She would worry about the pungent smell of vomitus in toilet and ask mother to clean it frequently. The fear increased slowly to the extent that, she started avoiding playing with other children in a fear that they will avoid her and tease her if she vomited in front of them. She avoided school for the same reason and thought that teachers will have bad impression about her if she vomits in the classroom. Meanwhile, parents asked their close relatives to console her. But symptoms went on increasing and she started refusing to use a lift, travel in bus, going to park, market places, etc., Fear became generalized and patient started worrying that her parent may suffer vomiting, she would request parents not to go outside, not to travel in bus or use lifts. Her father was working in a different city and job required frequent traveling. She had persistent fear that he may suffer vomiting as he eats outside food and there is no one to take care of him. She would call him repeatedly on phone and ask to change his job. She also developed reduced and non-refreshing sleep with constant thoughts/worries about vomiting at night with complaints of nausea and regurgitation after having her dinner. History of occasional nocturnal enuresis was also present during this period.

She was referred for a psychiatric consultation. She refused separate interview of parents because of the fear that they will hide the illness from her. She elaborated all the complaints and said “I feel nauseated even when I hear a word ‘vomitus’ or ‘vomiting’ or if I see anybody vomiting”. She elaborated the incidence when she vomited after witnessing the same in the neighborhood. Besides this, there was no history of depressive or obsessive-compulsive features or eating disorder and no symptoms suggestive of other phobias. Past history was not significant. There was significant family history and both of her parents are suffering from anxiety disorder and taking regular treatment from a psychiatrist. Birth and developmental history did not reveal any significant abnormality. She was good in academics.

On mental status examination, patient described her mood as anxious with appropriate affect. In thought, there was preoccupation about the worries of having nausea and vomiting along with number of questions e.g., whether I will get better; Do I have some severe illness; Will your medicines have side effect of vomiting, etc., She was diagnosed as a case of Specific Phobia of Vomiting i.e., Emetophobia.

As it was very difficult to involve the child in counseling or psychotherapy because of severe anxiety, she was prescribed tablet Clobazam 5 mg in divided doses and Cap Fluoxetine 10 mg. She was admitted to a child unit to reassure her as she was not willing to take medicines due to fear of side effects. After a week, she and her parents perceived mild improvement in anxiety and she was somewhat comfortable. On further follow-up, child was taught relaxation and started on Graded Exposure therapy along with the medications. She was exposed to the materials or activities related to vomiting. First, she was asked to read hand written article which contained the word ‘vomitus/vomiting’ (multiple times) as many times as possible. After about a week, she was asked to witness the action of vomiting by parents which they were pretending, followed by behavior as if vomiting has caused no trouble and anyone can suffer it for a short duration. After around 15 days, she was advised to attend school with a facility to go to rest room whenever she has thoughts of vomiting followed by feeling of nausea. She used the rest room only for initial 2 days after which she was as regular to the classes as before the start of illness. She was asked to play with other children only for 15 minutes to begin with. This time was increased slowly from 15 minutes to 1 hour. When she didn’t have even a single vomiting during this period, she started accepting the fact that it was an irrational fear and that she can achieve a mastery over it. Slowly, she was exposed to the activities that can induce vomiting like smelling the toilet, spinning around, etc., She had nausea and she hesitated to do it initially, but with intermittent counseling and relaxation and frequently doing above activities, she could face the feeling of nausea with less fear than before. In view of severity of symptoms and family history of anxiety disorders in parents, patient was advised to continue medications.

DISCUSSION

This case clearly presents with a persistent fear of vomiting, which is called as Emetophobia. Literature shows that emetophobia usually starts in the childhood and has a chronic course.[4] Our patient did not have symptoms suggestive of other types of phobia. According to some studies, the prevalence rate of fear of vomiting in the community sample is 8.8% (Female:Male ratio = 4:1).[2]

In this case, symptoms started with the remembrance of episode of acute appendicitis and research shows that people with emetophobia recall the memories of their own or others’ vomiting experiences from an earlier age and rate them as significantly distressing.[6] The present case study also illustrates that exposure to distressing or otherwise aversive situations can lay down the groundwork for phobic conditions like emetophobia. This correlates well with the data of a survey among emetophobics showing about one-third of patients reporting past memories of actual vomiting, and more than half had observed someone else vomiting.[3] The pattern of symptoms showed that severity increases from specific fear of vomiting to more generalized fear of suffering vomiting by family members over a period of 6-7 months. Like any other phobias, emetophobia is also associated with the avoidance behavior and the child stopped going to school, playing, traveling in bus, etc., because of fear of vomiting in front of others. This caused severe socio-educational impairment in the child. Evidence suggests that fear of vomiting is a chronic and disabling condition that may cause significant impairment in daily functioning.[2]

There are no treatment protocols and randomized controlled trials for the treatment of emetophobia, and exposure-based therapies are the most commonly used approaches for vomit phobia as described in literature. These approaches include simulated exposure,[7] interoceptive exposure[89] and graduated exposure to feared situations.[9] Other treatments that have been reported include the use of (combinations of) hypnotherapy,[10] cognitive behavior therapy including stimulation of nausea or vomiting, the use of counter conditioning,[5] exposure in vivo to cues of vomiting, re-scripting of past aversive experiences of vomiting, behavioral experiments, dropping of safety-seeking behaviors, and role play of vomiting using the smell of vomit.[11]

We mainly used graduated exposure to treat this patient and child started showing improvement. Our patient also received Fluoxetine and Clobazam treatment. Research shows that some psychotropic medications (such as benzodiazepines and antidepressants) do help in this phobia and some said gastrointestinal medications are also beneficial.[3]

CONCLUSIONS

The result of the present case study is in line with previous studies on phobias with people that have developed it following a disturbing event. More studies are needed for a better understanding of the epidemiology, clinical picture, etiology, and treatment of emetophobia. Emetophobia is relatively neglected illness although it can cause as much distress as other major psychiatric disorders do and any patient presenting with these symptoms need to be evaluated in detail. Fear of vomiting is not uncommon and can be disabling condition for a child leading to socio-occupational impairment.

The present study has certain limitation that it was not entirely clear whether the improvement was caused by medications or psychotherapy.