People with a fear of vomiting rarely arrive at a psychologist first. They arrive at a GP, then often a gastroenterologist, because the symptom they notice is nausea rather than fear.
A 2013 Austrian survey looked closely at that symptom. Höller and colleagues recruited 131 German-speaking people through an online emetophobia forum, all of whom met the criteria for specific phobia. Nearly all were women, with an average age of 26, and the fear had usually begun in childhood, around age nine.
Nausea was close to universal. Four in five reported it, most of them at least weekly and 43% daily. Two thirds said it interfered with ordinary daily activities. Almost half said it sometimes became strong enough that they felt they were about to vomit, yet 98% said they did not actually vomit when it happened.
The people with the most nausea also had the most intense fear and had lived with the fear longest. They were more likely to be underweight, with a body mass index under 19 found in more than a third of the whole sample. Only a small number of those had ever been assessed for an eating disorder.
That combination, persistent nausea and low body weight, is what makes emetophobia so easy to mistake for a gastrointestinal condition or an eating disorder. Recognising the fear behind the nausea is what changes the treatment.
Why nausea deserves attention
Specific phobia of vomiting, abbreviated SPOV, starts early, runs a chronic course and causes substantial disruption through avoidance. It is also poorly recognised. The authors cite research finding that 29.7% of eating disorder specialists had not heard of it. The symptom that most often brings a person with SPOV to a doctor is not fear but nausea, and the authors set out to examine what role nausea plays.
The theoretical case is a feedback loop. Fearing nausea as the first sign of vomiting produces selective attention and hypervigilance to gut sensations. Minor signs of ordinary digestion are read as the onset of nausea, which raises anxiety, which itself produces nausea. More nausea means more fear, which means more vigilance, which means stronger sensations.
Method
Participants were recruited through a German-language emetophobia forum. Questionnaires were returned by 154 people between October 2007 and June 2009. Those meeting DSM-IV criteria for specific phobia, judged by answers about fear of vomiting plus impairment or food avoidance plus other avoidance, were retained, leaving 131. The instrument had 36 items plus demographics and drew on items used in earlier SPOV research, with new items written for nausea and eating behaviour. Body mass index was calculated from self-reported height and weight. A nausea score was computed and used to split the sample into a high-nausea and a low-nausea group.
The sample
Of the 131 participants, 96.9% were women. Mean age was 26.47 years, ranging from 16 to 47. The fear had begun on average at 9.5 years of age. Mean self-rated fear was 86.8%. Just over half feared their own and others' vomiting equally, 35.1% mainly their own, and 8.4% mainly others'. Most reported greater fear in public than in private. Asked what specifically frightened them, 83.8% named the gagging feeling, 72.3% the sight, 71.5% the sound and 66.1% the smell.
Nausea findings
Nausea was reported by 80.9%. It came and went in 76.7% of those, while 23.3% described it as permanent. Frequency was daily for 43%, weekly or more often for 30.6%, one to three times monthly for 17.4%, and less than monthly for 9.1%, meaning it occurred at least weekly in 73.6% of the sample. Episodes lasted 30 minutes or less for 35.8%, about two hours for 23.3%, about four hours for 15.8%, and longer for 18.3%.
Nausea interfered with routine daily activities for 64.8%. Almost half, 45%, said it became so prominent that they nearly had to vomit, and 17.8% said that in some situations they would rather vomit than continue enduring it. Despite that, 98.3% said they did not actually vomit when nauseated.
Timing varied. In 46% of participants nausea and fear began at the same age. In 44.4% the fear came first, with nausea arriving on average 9.68 years later. In 8% nausea came first, on average 2.67 years before the fear.
Nausea, fear and body weight
The high-nausea group had significantly higher fear ratings and a significantly longer duration of fear than the low-nausea group. Locus of fear, meaning whether the person feared their own or others' vomiting, was not related to nausea group.
Mean body mass index in the sample was 20.3, ranging from 13.8 to 34.5. A BMI below 19 was found in 37.4% of participants, 56.5% were in the normal range and 6.1% were above 25. Among the underweight participants, 91.8% reported nausea to some degree, and the distribution of high and low nausea differed significantly between the underweight group and the rest. Only 16.1% of underweight participants had ever received an eating disorder diagnosis from a specialist. A comparison of BMI in those with and without eating-related avoidance was borderline rather than significant.
Most participants, 81.3%, had their own theories about what brought nausea on. Stress was named by 67.2%, particular foods by 52.5%, health concerns by 52.3%, illness by 46%, events at work by 43.1% and events in relationships by 41.6%.
Why it matters clinically
The authors' concern is misdiagnosis. Someone presenting with chronic nausea, food avoidance and low body weight can be worked up for a gastrointestinal disorder such as irritable bowel syndrome, or assessed for anorexia nervosa, without the fear of vomiting ever being identified. The study cannot say whether nausea causes the fear or the fear causes the nausea, and the authors are careful to state that it is not clearly a precursor or a consequence. What the data support is that nausea sits at the centre of the presentation, tracks with the intensity and duration of the fear, and is associated with lower body weight.
Limits
The sample was self-selected from an online support forum, was almost entirely female and German-speaking, and diagnosis was established by questionnaire rather than clinical interview. Body mass index was self-reported. The design is cross-sectional, so no causal direction can be established.
If persistent nausea has been investigated without a clear medical explanation, and you also avoid food, travel or crowds because of what the nausea might lead to, that combination is worth discussing with a psychologist familiar with this phobia.