Emetophobia: the fear of vomiting that is rarely talked about

“There’s a stomach bug in the group, three children are already at home,” the nursery teacher writes in the parents’ chat. Most people sigh and check whether there is enough tea in the cupboard. But someone, on reading that message, puts their fork down in the middle of dinner, washes their hands three times in a row, undresses their child in the hallway and then lies awake all night with their attention fixed on their own stomach. Not because they are already ill. But because there is a chance they will vomit, and for them that chance is worse than almost anything else.

Nobody finds vomiting pleasant. But there is a long distance between “I don’t like it” and a fear that determines what you eat, where you go, whom you spend time with and whether you will have children. That fear is called emetophobia, and it is talked about surprisingly little, even among the people who have it. Many go for years without knowing it has a name.

In this post I would like to describe how emetophobia shows itself, why it is so often mistaken for fussiness or an eating disorder, how it reaches into pregnancy and travel, and what we know about help and what we don’t yet know. On that last point I will be cautious, because there is little research.

What emetophobia is

Emetophobia is a marked, persistent fear of vomiting. The diagnostic manual DSM-5 places it among the specific phobias, in the “other” group, which also includes fears of choking. I explained what a phobia is, and why reason doesn’t switch it off, in the post Specific phobias, so here I will keep to what is particular about this one.

The fear comes in several versions. Some people mainly fear vomiting themselves. Others fear more seeing or hearing someone else vomit. For many both are present, often with a twist: “If he is sick, I’ll catch it and be sick too.” Vomiting in front of others is especially hard, because shame joins the fear. David Veale and Christina Lambrou, who in 2006 published one of the first more detailed studies of this phobia, described the fear of vomiting oneself as being at the forefront for most.

The odd thing is that people with emetophobia do not, as a rule, vomit more often than anyone else. Many will tell you they have not been sick for ten or twenty years. So the fear doesn’t grow out of frequent bad experiences. It grows out of how dreadful the person imagines the event to be, and out of everything they do to avoid it.

Why so little is known about it

For a phobia that narrows people’s lives so much, there is surprisingly little research. One fact is a good indicator: the first randomised controlled trial of treatment for emetophobia was published only in 2016, and it included 24 people. By comparison, for the fear of spiders or heights such studies go back decades.

Most of what we know comes from surveys of people who identified themselves, often through online self-help groups. Joshua Lipsitz and colleagues published the first findings of an internet survey in 2001, and in the years that followed David Veale and colleagues described how these people live and what they avoid. Such studies are valuable, but they have a limit: they tell us what it is like for the people who came forward, not what it is like for everyone.

Even so, a fairly consistent picture emerges. The fear often begins early, in childhood. As a rule it lasts a long time, without real breaks. Among those who take part in studies and seek help there are far more women than men. How common emetophobia is in the general population, however, we do not reliably know: estimates differ widely depending on whether researchers ask about fear of vomiting in general or about a phobia that meets diagnostic criteria. The 2018 systematic review by Alexandra Keyes and colleagues accordingly calls it an understudied disorder in its very title. So better no figure than an invented one.

The other reason for the silence is shame. You can mention a fear of flying over lunch. But that you fear vomiting so much that you don’t eat in restaurants is something people generally keep quiet about, afraid it will sound childish or strange. Some avoid even the word itself.

The loop in which fear itself creates nausea

The most unpleasant feature of emetophobia is that anxiety produces exactly the sensation the person fears. When the body’s alarm goes off, digestion slows, the stomach tightens, a lump forms in the throat, and nausea may appear. This is an ordinary part of the stress response. But for someone with emetophobia, nausea is proof that the worst is about to happen.

Added to this is excessive attention to the body. Our capacity to sense what is going on inside us is called interoception. In emetophobia that attention is turned towards the stomach and gullet all the time, like a sentry who must not fall asleep. And anyone who listens to their belly constantly will always hear something in it: fullness after lunch, rumbling, wind, hunger. All of these are everyday sensations that most people don’t even notice.

So the loop closes in on itself: the sensation triggers fear, fear intensifies the sensation, the intensified sensation confirms the fear. It cannot be broken from outside with an assurance that “you won’t be sick”, because nobody can promise that. And it is precisely this uncertainty that is hardest to bear in emetophobia.

Avoidance: food, places, people

Because vomiting cannot be prevented with certainty, the person tries to reduce every possibility of it. A web of rules forms and slowly spreads. I described how avoidance soothes in the short term and feeds fear in the long term in the post Anxiety and avoidance: why avoiding helps you today and harms you tomorrow. In emetophobia this web has three characteristic areas.

Food. Meat has to be overcooked. Shellfish, eggs, chicken, food from a self-service counter or a street stall are out. Use-by dates are checked several times, and food is thrown away a day or two early. Many people eat nothing they haven’t prepared themselves, or eat only small amounts, because a full stomach feels too much like nausea. Some don’t eat at all before important events.

Places and travel. A bus on a winding road, a boat, a plane, a long drive in the back seat: travel sickness, your own or someone else’s, is possible in all of them. So day trips fall away, as do holidays abroad where the food is unfamiliar, and sometimes public transport too. Places where people drink are hard: parties, concerts, New Year’s celebrations, late trains. Waiting rooms and hospitals are hard.

People. Anyone who mentions feeling sick yesterday becomes dangerous. Children are dangerous, because they fall ill often and vomit without warning. So some people avoid visiting friends with small children, jobs in health care and education, sometimes even their own nieces and nephews.

Avoidance also includes small safety behaviours: mints and anti-sickness medication in every bag, a bottle of water always to hand, a seat by the door, excessive hand-washing, checking where the toilet is, searching online for how long a stomach bug takes to incubate. Each one is understandable in isolation. Together they mean that fear runs the whole day.

Not an eating disorder, but it can look very like one

A person who eats little, chooses among a few “safe” dishes, loses weight and avoids shared meals looks from the outside as though they have anorexia. That is why people with emetophobia are not infrequently given the wrong explanation: by those close to them, and sometimes by professionals too. But the difference is essential, and it lies in the answer to the question of why you are not eating.

In anorexia and bulimia the fear of weight and body shape is at the centre; I wrote about what lies behind it in the post Eating disorders are not about food: what is really underneath. A person with emetophobia, by contrast, generally has no wish to be thinner. Often they would like to eat more and are worried about losing weight. They restrict food because they are afraid it will make them feel sick. In 2012 David Veale and colleagues described exactly this: some people with emetophobia restrict food markedly and some are underweight as a result, yet the reason is not body image but fear of vomiting.

One more difference is telling. In bulimia, vomiting is for some a way of “undoing” a meal. In emetophobia, vomiting is the thing to be avoided at any cost.

Things are not always that clear-cut, though. DSM-5 includes the diagnosis of avoidant/restrictive food intake disorder, in which a person restricts food without being concerned about weight, among other reasons out of fear of unpleasant consequences of eating such as choking or vomiting. So emetophobia and an eating disorder can overlap, and both can be present in the same person. What they also share is that food becomes a means of managing anxiety, which I described in the post When food becomes the only control: eating disorders and anxiety. That is why, with marked weight loss or a very narrow diet, a doctor’s assessment is essential whatever the cause.

Pregnancy: a wish that fear postpones

For many women with emetophobia the hardest question is pregnancy. Nausea in the early months is common and cannot be planned or prevented with certainty. Then comes the birth, and then a child who will certainly be sick at some point in the first years, most probably at night and most probably all over you.

As early as the internet survey by Joshua Lipsitz and colleagues, a noticeable share of the women said they had delayed or avoided pregnancy because of the fear. Later descriptions mention the same. Since these are surveys of people who came forward themselves, I would not generalise the proportion. It is enough to know that this happens and is not rare.

The painful part is that the people around often don’t know the reason. A couple who “aren’t ready for children yet” listen to questions and hints, while the truth is that she wants a child but cannot imagine nine months of uncertainty. Sometimes not even her partner knows, because the reason feels too shameful to say aloud.

If you are in this position, two things are worth doing. First, tell your gynaecologist or midwife about the fear. Nausea in pregnancy can in many cases be eased, and health professionals can tell you what is available; that decision is a medical one and doesn’t belong in a blog. Second, a fear strong enough to decide about a family is reason enough to seek professional help, even before you conceive. There is more about anxiety in this period in the post Anxiety in pregnancy and after birth: what mothers rarely talk about.

A conversation repeated every evening

Emetophobia almost always draws someone else in. The partner becomes the one who checks, reassures and adapts.

“Did you wash your hands when you came in?”
“I did.”
“With soap? Maja said her little one was ill yesterday.”
“With soap. Like every time.”
“And the chicken, does it look cooked enough to you? Look in the middle.”
“It’s cooked. You’ve asked me twice already.”
“I know. I’m sorry. Just tell me once more that I won’t be sick.”
“I can’t promise you that. But I can stay with you, even if you do feel sick.”

(The dialogue is composed; it does not describe a real person.)

That last sentence is harder than it looks. It is far easier to say “you won’t be sick” and have ten minutes’ peace. But reassurance works like any other safety behaviour: it soothes briefly and increases the need for the next one. I explained why that is, and how someone close can respond differently without being cold, in the post Checking and reassurance-seeking: why the relief is so short-lived.

A partner in such a relationship often swings between patience and anger. He adjusts the menu, cancels dinners, goes on visits alone. Over time a tiredness builds up that he cannot talk about, because he knows she isn’t doing it on purpose. That too is part of the picture and deserves a place of its own.

What helps and what we don’t yet know

The best-described approach to emetophobia is cognitive behavioural therapy with exposure. In 2009 David Veale set out in detail what it looks like: gradually dropping safety behaviours and avoidance, bringing back “forbidden” foods and places, getting used to the bodily sensations of nausea, working with words, sounds and images of vomiting and, where needed, with memories of early experiences of vomiting that were stamped in as especially dreadful. Exposure here does not mean the person has to vomit. It means approaching everything that fear has removed from their life.

In the 2016 trial already mentioned, led by Lori Riddle-Walker, the group that received this therapy improved more than the group on the waiting list. That is encouraging. It is only fair to add, though, that this is one small study, that not everyone improved, and that we know little about how lasting the effects are. Anyone who promises you a reliable cure in a few sessions is promising more than the research supports.

This therapy is delivered by cognitive behavioural therapists and clinical psychologists; in Slovenia’s public system, a referral from your GP leads to a clinical psychologist or psychiatrist. I do not deliver it myself. As a therapist in training in marriage and family therapy, working under supervision, I can offer something different: a space for the shame that has gathered around the fear, for a relationship that has reshaped itself around the rules, for the conversation about children that a couple keeps putting off, and for the question of where in your life such a strong need comes from that nothing may happen without warning. I meet clients in person in Ljubljana and also work with English speakers. This can sit alongside treatment for the phobia or be a first step towards it, not a replacement for it.

Exercise: a map of avoidance

This exercise does not remove the fear. But it shows you how much room it has taken up, and helps you choose the first place where you can take some back. You need a sheet of paper and half an hour of quiet.

1. List everything you do or give up because of the fear. Foods you don’t eat. Places you don’t go. People you avoid. Rituals: checking dates, mints in your bag, questions to your partner. Write without judging until the list feels complete.
2. Beside each item, write what it costs you. From 0 to 10: how much does it take away from the life you would like to have? A cancelled holiday may be a 9, an overcooked steak a 2.
3. Beside each item, write how hard it would be to give up. Again from 0 to 10. This gives you two columns of numbers.
4. Find an item with a high cost and low difficulty. That is your first rung. Write down a small, concrete experiment for this week, for example: “On Thursday I’ll go for coffee without mints in my bag.” The aim is ordinary behaviour of the kind most people have, not risk. The exposure ladder tool will help.
5. Write a prediction before the experiment and the outcome after it. What do you expect to happen? What did happen? What did you learn about your nausea when you didn’t try to switch it off?

If your diet is already very narrow or you have recently lost a noticeable amount of weight, don’t do this exercise with food by yourself. See your GP first.

Where this explanation doesn’t apply

Nausea can have a physical cause. Frequent nausea, vomiting, abdominal pain or unintended weight loss are a reason to see a doctor, not to conclude that it is “all in your head”. A phobia and a physical illness do not rule each other out.

Not every aversion to vomiting is a phobia. Almost nobody likes being sick, and most people keep their distance when there is a bug in the house. We speak of a phobia when fear directs everyday decisions and visibly narrows life.

Sometimes something else is at the forefront. Washing and checking rituals can be part of obsessive-compulsive disorder. Fear of feeling sick in public can be part of panic disorder or social anxiety. A narrow diet can be an eating disorder. In real life these boundaries are blurred, so they should be assessed by a psychiatrist or clinical psychologist.

With a child the route is different. If a child refuses to eat, go to school or sleep alone for fear of vomiting, the first port of call is the paediatrician, who will direct you onwards. I do not work individually with minors; family therapy can make sense, though, when the fear has rearranged the whole family’s life.

When not to wait. If fear means you are barely eating or drinking, if you are losing weight fast or feel you can’t go on, seek help straight away: from your GP or the emergency services on 112. In acute distress in Slovenia you can call the mental health helpline Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samarijan confidential helpline on 116 123 (24 hours a day).

What to remember

• Emetophobia is a specific phobia of vomiting that often starts early and lasts a long time, and that people rarely talk about out of shame.
• Anxiety itself causes nausea, so the fear keeps receiving “proof” that it is justified.
• In emetophobia, restricting food is a consequence of fearing nausea, not of wanting to weigh less; with weight loss, a doctor’s assessment is essential all the same.
• The fear can reach into the decision to become pregnant, into travel and into a couple’s relationship, where the partner becomes a source of reassurance.
• The best-described help is cognitive behavioural therapy with exposure; the research is sparse but encouraging.