What Causes Emetophobia?

How A Phobia Starts and Builds

Sometimes with anxiety disorders it is very hard to find a specific event or events that seem to the cause. Part of the reason for this is that anxiety is often a matter of association or correlation and not cause and effect. Something is present at the same time there is anxiety. For example, if someone has a panic attack at a stop light it might feel like there is something about the stoplight or similar situations that cause the panic. However, it may be the actual cause is completely unrelated but the anxiety becomes associated to stop lights. Therefore, it may be difficult to determine the cause. Happily, as far as treatment is concerned, knowing the initial cause or causes is probably not as important as it is with other psychological struggles.

That being said, at least in my experience, emetophobia probably has a clear beginning point as often as not. Even with that clear sense of beginning, the process of it continuing and likely strengthening is more important to understand. If someone doesn’t know why their fear started that won’t hinder successful treatment. In fact, I generally don’t spend much time trying to figure that out. Any relevant memories important for treatment will probably come to mind during the process.

It is important 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 as helpful as understanding “how”. This is a useful way to generally think of the process but not everyone’s experience may line up with this precisely.

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 th**w up or internal as in imagining yourself vo**ting. 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. This trigger or triggers could have been part of the initial onset of the phobia or part of the ongoing problem if the phobia is already present.

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 excessively 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 is in actuality. For example, thr**ing 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 rarely 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, for example, when there are just dark clouds and that it interferes with their lives.

Human beings learn fear FAST and generalize 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 a biological favoritism for learning to be afraid. It isn’t hard to imagine that same process going a bit too far.

However, a problem begins when the fear spreads to things associated to the specific threat that are imagined as far more dangerous than they are in reality. The key word is imagined. It is a mental movie about something that might happen. In the case of emetophobia, vo**ting is misinterpreted as a threat. (Sometimes, embarrassment of vo**ting 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 stomach 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, Distress

So there is a trigger, then misinterpretation, followed by intense anxiety. In the early stages of a phobia the anxiety may not be that strong. In fact, lots of people can remember getting sick before the phobia and not being that alarmed at all. However, once the phobia has developed the anxiety will get very intense.

Although the imagined danger is not real, the experience of distress is real. Sometimes when I watch TV there is a scene that is so vivid to me that I can actually feel what it would be like. I recently saw a scene where someone base jumped (parachuted) off a building and I felt something like what I imagine the feeling would be and it is NOT on my to-do list. Our body will create a simulated feeling for something that scares us. I think it wants to make sure we fully understand the problem! That simulated feeling can be part of the phobia. 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 defend itself. In the wrong circumstances it can become part of an anxiety disorder. Panic while running from a charging rhinoceros is extremely useful. Panic while sitting in a classroom, not so much. It is similar physiology but interpreted differently.

Anxiety disorders are incongruence between what a person is thinking and feeling compared to the actual situation. Using our previous example, the anxiety about being hit by lightning is evoked by dark clouds. As mentioned earlier, the fear becomes associated with more and more things. The physical reaction is just as strong (if not stronger) for the imagined problem as for the actual situation. For emetophobia there is extreme distress at the possibility of vo**ting. The anxiety leaps (associates) to anything that might lead to vo**ting. (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 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 disorders only happen when there is not a literal threat, only the possibility, however unlikely. Because the anxiety “feels” real and the avoiding “feels” better this becomes enormously influential. Because this becomes the pattern, the next step seals the deal. (As a side note, even if the sufferer knows that he or she is overreacting, that is still unlikely to be enough to stop the cycle. That is why it is extremely unlikely you can talk someone out of a phobia with just logic. A different kind of knowledge is needed.)

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 “proof” that it is threating. Not concrete or factual evidence just more imagined proof. For example, if a child is afraid of vo**ting, she or he might begin to hyper-focus on how their 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. A person might feel nausea for some reason. Hunger can be very uncomfortable. If that causes anxiety, then anxiety can lead to nausea. This normal distress is misinterpreted as increased likelihood of vo**ting and is avoided if possible. She or he might change eating habits if they think the feeling is connected to a certain food. Food can be restricted. That food is now added to the associated threats that could lead to getting sick. Mind you, it is avoided so there is no evidence to the contrary that is isn’t really a dangerous food (assuming there is not a legitimate allergy or condition like gluten intolerance). Each additional association becomes more false evidence of threat.

As the phobia grows the sufferer is worried most of the time, that leads to scanning for evidence of trouble and they will gradually “discover” more and more potential threats. The triggers remain triggers because they are never challenged, and repetition strengthens the cycle.

The Cycle for Emetophobia

So how does it work with emetophobia? No one likes to feel nauseated and sick. Vo**ting is unpleasant. However, vo**ting is NOT dangerous or threatening. Imagine a young child I will call McKay.

Step 1: The Trigger. McKay is at school and sees some students get miserably sick and then thr*w *p. McKay sees, hears, and smells it. Lots of kids are getting sick. There is a normal disgust response people have to gross things. McKay feels that feeling and it results in the urge to gag.

Step 2: Misinterpretation. McKay naturally thinks one could get sick if this is a virus or food poisoning. McKay imagines it would be an overwhelmingly terrible experience and possibly humiliating. Sufferers often think it would last much longer than it does and that the amount is far greater than it actually can be. They imagine the experience as excruciating. They interpret it as far worse than it would be in actuality.

Step 3: Anxiety. McKay begins to feel anxious about getting sick. Like anyone with this fear, they begin to scan their body for any signs of getting sick. The anxiety itself causes them to feel stomach distress. Then they get anxious about being anxious.

Step 4: Avoidance. McKay wants to stay home while the bug is going through the school. Even after it is over, McKay still thinks it will be safer to be at home. She avoids anyone who might be sick and listens carefully for anyone saying anything about being sick. McKay wants to know if it is something that could cause one to th**w *p. She avoids anything that might be contaminated with the virus. McKay starts to ask her parents if she is sick. She wants them to check her temperature. She wants reassurance she isn’t sick.

Step 5: No corrective experiences. This is simply the result of avoiding. McKay finds ways to not go to school. At the first hint of trouble, she is off to the nurse’s office. Her parents reassure her she is not sick and start to make accommodations, so she won’t panic. She requires more and more reassurance. McKay stops eating before she is full, she limits her diet to safe foods. She won’t sleep alone in case she gets sick at night. The list gets longer as more possible problems occur to her. All of these behaviors designed to make her safer prevent her from discovering she doesn’t need them. That is the ultimate deception of anxiety disorders. She won’t know if she is okay without all these safety behaviors unless she stops them. At this point she probably has the belief, “Better safe than sorry, right?”

The cycle just gets stronger. The triggers get more alarming and without the corrective experiences, the misinterpretation seems more convincing which increases the anxiety. The urge to avoid gets extreme because it gives immediate relief and they don’t realize that is making the phobia worse. Fast relief but long-term trouble is the result.

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