A 26-year-old woman came to a university clinic because she and her fiancé wanted to start a family and she could not face the possibility of morning sickness. She had not vomited since she was in sixth grade, following an episode in which she had choked and believed she was dying. Asked how likely she thought it was that she would die if she vomited, her gut answer was 50%, though she knew logically it was much lower.
Maack, Deacon and Zhao published her treatment in 2013. It was exposure therapy, worked through a hierarchy she built herself. Early steps were video clips, graded from mild to severe. Later steps included cooking and eating meat she would previously have overcooked, deliberately overeating, and dropping the safety behaviours she used whenever her stomach felt unsettled. She also gave up the antacids she carried.
Three years later her scores had changed substantially. A measure of fear of bodily sensations fell from 34 to 2. Obsessive-compulsive symptoms fell from 12 to 4, and both scales of a body vigilance measure came down. She had stopped her safety behaviours, was no longer taking medication, was married, and she and her husband were trying to conceive. She had also been able to look after her husband when he was unwell.
One case cannot prove a treatment works. It does show, in detail, what a full course of exposure for this fear can look like and what can still be true three years on.
The presenting problem
The client, given the name Lindsey, was a 26-year-old woman referred for emetophobia. Her central concern was practical: she wanted to conceive, and could not, because she believed morning sickness would make her vomit, that she would choke on the vomit, and that she would die. She reported intrusive images and thoughts about vomiting, a sensation of choking or suffocating whenever she thought about it, and a belief that if she vomited she might swallow her tongue.
She had not vomited since sixth grade, when she came home ill from school and vomited repeatedly, choked on it, and felt she was going to die. Since then she had been hypervigilant to any stomach sensation and had trained herself, deliberately and over years, to avoid any situation in which vomiting was possible. Asked to estimate the risk of dying if she vomited, she gave a gut figure of 50% while acknowledging that a logical figure was closer to 10%.
She also had a history of Tourette's disorder and obsessive-compulsive disorder, both diagnosed in junior high. Current OCD symptoms centred on ordering, symmetry and checking. She specifically denied any contamination fear or compulsive behaviour connected to vomiting, which helped separate the two diagnoses.
Measures
Three self-report measures were used: the Anxiety Sensitivity Index-3, an 18-item measure of fear of arousal-related bodily sensations; the Obsessive Compulsive Inventory-Revised; and the Body Vigilance Scale, which has separate scores for attention to internal bodily sensations and sensitivity to changes in them. The authors note as a limitation that none of these is specific to emetophobia. Two emetophobia-specific instruments, the Emetophobia Questionnaire and the Specific Phobia of Vomiting Inventory, were not available when the treatment was carried out.
Course of treatment
Treatment was exposure therapy guided by a fear hierarchy the client helped construct, with actual vomiting placed at the top as the eventual goal.
Exposure began in the first session with graded video clips, starting with college students deliberately making themselves sick after drinking milk and progressing to footage of someone acutely unwell. Her anxiety to the mildest clip was rated 6 out of 10 and fell with repeated viewing. Homework was 30 minutes of new clips daily, each chosen to be more distressing than the last.
In vivo work followed. She cooked and ate chicken without overcooking it, deliberately overate, met the therapists at a restaurant to order a medium rare burger and then walk briskly, and stopped using safety behaviours in response to stomach sensations. A second hierarchy was then built for the final stage: modelling and practising simulated vomiting, watching others vomit and studying what actually happened to them, vomiting with someone present, and vomiting alone.
Progress stalled at that point. She arrived at one session without having done the homework, and it was agreed openly that if she was unwilling to take the remaining step, continuing with exposures that no longer produced distress made little sense. A specific plan was set for the following week.
She did not return for another session. She telephoned the supervising psychologist to say that after that conversation she had gone home and vomited, that it had been a freeing experience, that she had since done it again with her husband and then her mother present, and that she no longer understood why she had thought vomiting was dangerous. She did not feel she needed further treatment.
Three-year follow-up
Contacted by telephone in February 2010, she was married and actively trying to conceive. She reported some residual apprehension about vomiting, but not enough to stop her exercising, cooking meat, or trying for a pregnancy, and she had been able to care for her husband when he was sick the month before.
Questionnaires posted to her showed the change numerically. The Anxiety Sensitivity Index-3 fell from 34 at pretreatment to 2 at follow-up. The Obsessive Compulsive Inventory-Revised fell from 12 to 4. On the Body Vigilance Scale, attention to internal sensations fell from 10 to 8 and sensitivity to changes in them from 8 to 3. She reported no safety behaviours, no prescription medication, and nothing avoided for fear of vomiting. Her remaining concern was about choking and panicking, not about dying.
Interpretation and limits
The authors read this as support for the cognitive behavioural model of emetophobia and for exposure as the active treatment, with the client's own view being that facing actual vomiting, rather than imagining or watching it, was the necessary step for her. That is an individual judgement made within a specific case, not a general prescription about how far a hierarchy must go.
The design carries the usual limits of a single case: no control condition, no randomisation, self-report measures not designed for this phobia, and no way to rule out other influences over three years. The authors call for randomised trials.
If a fear of vomiting is shaping decisions as large as whether to have children, it is treatable, and the evidence for exposure-based work is the strongest available.