Mental Illness 2012; volume 4:e3

Treatment of a woman with with emetophobia, the avoidance response must be very distressing and have a significant Correspondence: Ad de Jongh, Department of emetophobia: a trauma focused impact on the person’s life. As a result, emeto - Behavioral Sciences, Academic Centre for approach phobics have a tendency to avoid a wide array Dentistry Amsterdam, Louwesweg 1, 1066 EA of situations or activities that they believe Amsterdam, The Netherlands. Ad de Jongh might increase the risk of . For exam - E-mail: [email protected] Department of Behavioral Sciences, ple, they may avoid crowded places from which they fear they cannot quickly escape in case of Key words: specific , vomiting phobia, ACTA, University of Amsterdam and emetophobia, EMDR. nausea or vomiting, such as shops, boats, air - Vrije Universiteit Amsterdam, planes, concerts and hospitals. In addition, The Netherlands; Received for publication: 28 August 2011. they may not be able to go on holiday or travel School of Health Sciences, Revision received: 2 December 2011. on public transport, but the avoidance behavior Accepted for publication: 2 December 2011. Salford University, Manchester, UK could also pertain to avoiding adults or chil - dren who may be ill (and, therefore, regarded This work is licensed under a Creative Commons as contagious) or who are at risk of vomiting Attribution NonCommercial 3.0 License (CC BY- NC 3.0). (e.g. people who are drunk). The avoidance Abstract might extend to using public toilets or door ©Copyright A. de Jongh, 2012 handles, medication, going to the dentist, Licensee PAGEPress srl, Italy A disproportionate fear of vomiting, or eme - restricting the activities of their children who Mental Illness 2012; 4:e3 tophobia, is a chronic and disabling condition may be in contact with other children, or to doi:10.4081/mi.2012.e3 which is characterized by a tendency to avoid a certain food which they believe could cause wide array of situations or activities that might vomiting, which may lead to being significant - increase the risk of vomiting. Unlike many ly . 4,6,7 among a group of 7 patients. 3 Up to 13 sessions other subtypes of , emetophobia The sudden nausea and in emeto - were conducted in which the participants were is fairly difficult to treat. In fact, there are only phobia seems to have many similarities with asked to repeatedly view video sequences. The a few published cases in the literature. This panic disorder 8 and . 6 The differ - author noted that a subgroup of patients paper presents a case of a 46-year old woman ence between emetophobia and panic disorder, required a greater number of sessions because with emetophobia in which a trauma-focused however, is that the panic caused by emeto - treatment approach was applied; that is, an phobia is usually of much shorter duration fear returned between the exposure sessions. approach particularly aimed at processing dis - than that of panic disorder. Furthermore, the This observation is in line with the results of turbing memories of a series of events which avoidance behavior of emetophobics covers a an internet survey among 56, mostly female, were considered to be causal in the etiology of much wider range of situations than seen in individuals which showed that those who suf - her condition. Four therapy sessions of Eye agoraphobia, including the avoiding of drink - fer from emetophobia are likely to have under - Movement Desensitization and Reprocessing ing , becoming pregnant, contact with gone a wide range of previous treatments but (EMDR) produced a lasting decrease in symp - sick people and people with a degree of unpre - with fairly limited success. 6 tomatology. A 3-year follow up showed no indi - dictability, like children or the mentally handi - Eye Movement Desensitization and Repro - cation of relapse. capped. 6 More specifically, the behavior of cessing (EMDR) is a recommended treatment emetophobics is primarily aimed at the pre - for posttraumatic stress-disorder or PTSD. 16,17 vention of nausea and vomiting and not, as is Given that emetophobics frequently report a the case of agoraphobia, to avoid situations childhood onset, often following exposure to Introduction where the thought comes to mind of not being distressing experiences of vomiting or seeing able to get help when misinterpreting bodily others vomit, 6 and that EMDR is capable of A phobia of vomiting, or emetophobia, is a signs of anxiety. resolving disturbing memories of a wide variety condition characterized by a disproportionate If left untreated, emetophobia is likely to of events, including those that explain the onset fear of vomiting or other people vomiting, and persist. Knowledge on how emetophobia of phobic conditions, 18 one might argue that is generally associated with an overwhelming should be treated is limited, partly because of emetophobia is also responsive to EMDR. sense of losing control, becoming very ill, or the lack of any controlled trial on the (relative) Among the types of that have been that others will find them repulsive. efficacy of treatment strategies for this condi - reported as being successfully treated by using Individuals with this condition have a tenden - tion. In fact, there are only a few published EMDR ( e.g. phobias of traffic, snakes, moths, cy to check and monitor interoceptive stimuli cases in the literature. Treatments that have spiders, mice, injections, dental treatment, and such as nausea that in turn makes them more been reported include the use of (combina - choking), 19-21 there is one case report in the lit - likely to feel sick. 1 tions of) hypnotherapy, 9-10 cognitive behavior erature in which EMDR was used to treat a fear Estimates about the prevalence of emetopho - therapy including stimulation of nausea or of nausea and vomiting. 22 This approach led to bia suggest that it is a rare condition occurring vomiting, 11,12 the use of counter condition - complete remission of complaints following only in about 0.1% of the population. 2 Conversely, in ing, 13 interoceptive exposure, 1,14 exposure in one session of EMDR. its milder form, fear of vomiting is fairly com - vivo to cues of vomiting, re-scripting of past The aim of the present case study was to fur - mon in the community with estimates of point aversive experiences of vomiting, behavioral ther explore the clinical usefulness of EMDR prevalence rates ranging from 3.1 to 8.8%, and experiments, dropping of safety-seeking for treating emetophobia. To provide the read - women being four times more likely to suffer behaviors, and role play of vomiting using the er with an impression of how the therapy was from fear of vomiting than men. 3,4 smell of vomit. 15 experienced by the client, special attention Emetophobia belongs to the category of spe - It would seem that emetophobia is a condi - was paid to her personal notes and the cogni - cific phobia (Other Type) according to the cur - tion that is relatively hard to treat. The most tive, emotional and behavioral changes that rent edition of the Diagnostic and Statistical comprehensive treatment study used repeated she reported by e-mail both during the period Manual of Mental Disorders. 5 To be diagnosed exposure to film footage of people vomiting she was in therapy and at follow up.

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aspects of it. The client must focus specifically mess on the table, the moment that my class Case Report on the most distressing image and a dysfunc - mate vomits all over the table . The feeling that tional negative belief of oneself in relation to this picture evoked in Debbie was one of pure Subject the image, as well as accompanying emotions powerlessness (NC= I am powerless ), and Debbie is a 46-year old office worker who had and bodily sensations. A core feature of the pro - appeared to be emotionally charged (SUD=8). been suffering from an excessive and unrea - cedure is the performance of eye-movements. After starting the EMDR procedure, an intense sonable fear of vomiting for as long as she could Typically, the therapist moves his or her fingers flow of thoughts immediately started in remember. She had always done everything in back and forth in front of the client, asking him Debbie’s mind. She quite rapidly associated her power to avoid seeing other people vomit, or her to track the movements with the eyes the event at the kindergarten with other rele - 27 including her own children, as she was afraid while concentrating on the trauma memory. vant events related to the main one. Thoughts that it would make her want to throw up herself. Following the image and negative cognition and memories arose that were associated with Debbie, therefore, avoided all kinds of situa - (NC), access to the emotional and somatic Debbie’s early school years. During the second aspects of the memory takes place. After each tions, among which visits to hospitals, and set, she suddenly burst into tears when she series of eye movements (termed a set ) the watching certain television programs and films, realized how much fun she had actually client is asked to report emotional, cognitive, from fear of seeing people that might feel missed because as a child she was always so somatic and/or imagistic experiences until unwell, and who therefore might vomit. fearful. In the following set, Debbie saw all internal disturbances reach a SUDs (subjective Because Debbie had gradually been avoiding kinds of nice things, jars of paste and such that unit of disturbances scale ranging from 10 to 0) more and more of these situations in her daily had once been present in her kindergarten of zero and adaptive and positive cognitions life, her world had shrunk considerably. class. At the end of this chain of associations, (PC) are rated strong on a VoC (validity of cog - when going back to the initial target memory, nition) scale, ranging from 1 (feels completely she indicated: It is really a strange thing when Assessment untrue) to 7 (feels completely true). For the I see the event, it seems as if I saw it changing To assess whether Debbie’s fear of vomiting application of EMDR with phobias, there are a from very small and detailed into something would meet the diagnostic criteria for specific number of elements added to the procedure, much broader. Not only the perspective of that phobia (emetophobia) in terms of DSM-IV-TR, including a preparation for future confronta - table, where it happened, but also everything the diagnosis was established with a standard - tions with the phobic stimulus. 28 around it, but in their normal proportions . ized diagnostic interview: the Mini Interna- A wide range of experimental studies tional Neuropsychiatric Interview, version demonstrates that eye movements during After the following set, new memories arose. 5.0.0. 23,24 This also evaluates the presence of recall of aversive memories reduce their vivid - Then, suddenly, there was an expression of coexisting disorders and helps clinicians make ness and emotionality. 28-29 Recalling a trau - calm on her face: Yes, what is actually disgust - a differential diagnosis between emetophobia matic memory is assumed to tax the working ing about it? ...The picture that I had always and, for example, panic disorder. Emetophobia memory capacity which is reduced. If another had of it in my mind’s eye seems to be simply appeared to be Debbie’s only diagnosis. task is executed during recall, less capacity will disappearing . But this amazement was rapidly To determine the severity of Debbie’s symp - be available for recalling a distressing event. 30 followed by a new memory that came to mind: toms, she was asked to fill out the Dutch ver - This means that the memory is experienced as My parents were away and I had to babysit. He sion of the Symptom Check List-90-Revised less vivid and emotional. Although eye move - felt nauseated and thought he would make it to version (SCL-90-R). 25-26 This consists of 90 ments are believed to serve as such a second - the bathroom, but only made it to the kitchen. items providing an indication of psychological ary task, 28-29 also other modalities can be What a disaster! dysfunctioning on eight dimensions: agora - applied to tax working memory. In the present Debbie added that she had panicked and had phobia (7 items), somatization (12 items), case, EMDR was carried out using headphones run to the woman who lived next door to ask anger-hostility (6 items), depression (16 connected to a CD-player on which alternating for help. But she had replied that she was not items), interpersonal sensitivity and paranoid tones ( clicks ) were played. able to help either, as she herself could also not ideation (18 items), anxiety (10 items), cogni - tolerate vomiting and vomit. Debbie could still tive-performance difficulty (9 items), and Case conceptualization remember very clearly that she was allowed to sleep disturbance (3 items). The Dutch ver - EMDR is based on a model that focuses on use the neighbor’s telephone to call her par - sion differs from Derogatis’ original version in distressing events in the individual’s life that ents: Then father came home to clean it up, but that patients are requested to indicate the remain unresolved and that are causal in the afterwards he left again . In a clearly emotional number of complaints they experienced during etiology of the psychological disorder. Initially, way, Debbie said that with the return of this the previous week on a 5-point scale (1=none; Debbie indicated that she could not remember image she felt fearful and deserted again: I lay 5=very many). The total score is the sum of the when she had started being afraid of vomiting. frozen stiff with fear in my bed, listening care - items of the eight subscales, including nine To help Debbie access memories that are con - fully in case I heard anything . But above all, non-scalable items, and can vary between 90 sidered crucial with regard to the origins and what was really painful about the event for and 450. Debbie’s total score was 275. This fell maintenance of her symptoms, the Two Debbie was the fact that her father did not see in the very high range (norm group 2) on the Method model was used. 31 Debbie remembered her problem: No one even saw my fear. The dimensions anxiety , agoraphobia and interper - an occurrence that had taken place while she entire vomiting situation was even driven into sonal sensitivity . was in kindergarten in which a child in her the background by this . class threw up over a table. According to After this interlude, the EMDR was started Procedure Debbie, she must have been about four years up again to process the memory of the kinder - EMDR is a protocolized, 8-phase psychother - old at that time. It was decided to reprocess garten until Debbie was able to look at this apeutic approach aimed at resolving symptoms this memory first. event without experiencing any disturbance. resulting from disturbing and unprocessed life Next, it was agreed with Debbie to conclude experiences. 27 It begins with a focus on the The first treatment session the session, and that she would keep a journal traumatic memory itself by asking the client to The most disturbing picture of Debbie’s for the next few days with the request to e-mail recall the memory and to concentrate on various memory of the kindergarten appeared to be the this to the therapist.

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After the first treatment session even turned the page back another time and home. He felt terrible and I heard him vomit - Four days later Debbie e-mailed the follow - continued to look at the picture for a few min - ing. In the past, this sound alone would have ing text: It was an exceptional experience. That utes, while inside myself I said: ‘Actually such a created a panic reaction in me. I would have you can take a memory that you have and it has drawing doesn’t mean a thing’. I can hardly covered my ears in order not to have to hear it, always been the same, but that it gradually believe it . and I would have felt terribly nauseous. And enlarges. The sound in your ears has such a now? Amazing. I remained calm. I simply went calming effect and it seems as though it helps The third treatment session to lie beside him on the bed without worrying you process a memory in a positive way. I don’t At the beginning of the third treatment ses - about whether he might vomit again. Or: could know whether I am describing it well, but that sion, Debbie reports that she had noticed that that meat have been spoiled, so that I will is how I experienced it. I was dead tired from she could stand up for herself much more than become sick shortly, too? No. Nothing of the all the emotions that arose during the treat - in the past. Her husband had noticed it, too, as sort. I simply slept . ment. Yet, I can already tell you now that my had her colleagues: We are understaffed where first memory of kindergarten already feels very I work. And this is not the first time. The last Fourth treatment session neutral. That I even thought back with pleasure few times I worried about the work that had to In the fourth session, a so-called future tem - on it today. The image of filling the paste jars be done and worked overtime for hours. plate was installed; a blueprint of a positive came up again, which I always enjoyed so Nothing was ever said about this; no one appre - action in the future. More specifically, Debbie much, and also the sweet face of the teacher. ciated it. Now I work my normal hours and just was asked what she, in terms of her fear of The second memory that we dealt with; push whatever is not finished aside: without nausea and vomiting, still did not dare to do or home – apartment – brother that vomited and any feelings of guilt . any particular situation she still avoided. my father... this is not yet really neutral, I must In the last week, she had remembered that, Debbie answered that she now thought she say. Although I do find it surprising that I could when she was still in primary school, she had could deal with virtually all situations related suddenly remember many details of my room gone on a school trip with a bus. Someone had to vomiting in daily life. However, she still con - back then, and that was actually nice. But with become nauseated while they were traveling sidered it unpleasant to take long bus trips, as this memory, in addition with the vomiting sit - along. At present, the idea of not being able to she would have to accept that she could not uation another feeling came more strongly for - get off the bus was still being experienced as simply get off the bus just like that, for exam - ward, it seems...; not heard, not seen. I am not very frightening and had to do with helpless - ple, if someone might have to vomit. Debbie there. I will keep a journal and look forward to ness. After a while, the memory slowly began was asked to imagine how it would feel to take the next time . to feel neutral, and after one hour this treat - such a long bus trip, an image that included ment session could also be concluded. herself and one from which she could not sim - The second treatment session ply walk away. Debbie was requested to hold on After the third treatment session In the journal that Debbie had kept since the to this image in her mind and at the same time previous session, a number of other events After the third treatment session, Debbie e- say to herself: the PC I can handle it . Then a came up that possibly have played a role in mailed: During the last treatment it seems as new series of sets was introduced and this pro - worsening or maintaining her fear. She though a sort of screen was put up. I sat in the cedure was repeated a few times. The confi - bus during a school trip. One of my classmates described an event that happened a few days dence of being able to deal with the image suffered from carsickness and my fear that he earlier when a car suddenly slowed down in increased a little after each set. After a VOC of would vomit seized me. It was very uncomfort - front of her and drove into the bicycle lane: An 7 was reached, Debbie was asked to what able to experience that feeling again, all the unusual place. At that moment I felt a rush of extent she thought she was capable of taking - more so when I was asked what I could do. If I adrenalin and my thoughts flashed back to I such a bus trip, and she answered: Entirely . could just tell someone that I feel so trapped, so don’t know how many years ago (as I write this, anxious. To whom could I say this? Wham! The I see the images before me again). A car stops. I After the fourth treatment session screen! To the person sitting next to me. And see that someone is just getting back in, and When Debbie and her therapist met for the who is beside me always and everywhere? My then opens his door again and vomits . last time, Debbie indicated that she had friend Nicky. And it was specifically Nicky that It was decided to also make this memory planned the bus trip, and that there were no I would never dare telling this. As I write this I part of the treatment. But first the memory of longer any situations that she still feared. In feel that intense emotion again! It suddenly Debbie’s father that cleaned up the vomit of fact, over the past few weeks she had not became so clear to me how much impact this her brother was targeted once again. The emo - thought about her vomiting problem at all. To ‘friendship’ had on me. I didn’t dare tell her out tional burden of this memory (SUD) could also of fear of not being understood. To feel the dis - measure the effects of treatment Debbie was be brought down to 0. Then, five minutes later dain of Nicky; who never complained about asked to fill out an SCL-90 again. It appeared after the installation phase, she could project anything and was always brave. What could I that there were no high subscale scores with the image in her mind and feel that she was do? I kept going around in the same circle and the total score being 121 ( average ). definitely worth something after all. This was did not know it. Then the therapist asked me if Accordingly, it was decided to discontinue the followed by the vomiting scene of the car that it would be useful to simply look out the win - treatment for the time being with the restric - had stopped, and this memory was also suc - dow, maybe there was something interesting to tion that, if needed, she would contact the cessfully processed. see outside. A miracle, it worked! And that therapist again. worked the next week, too, at work. During an After the second treatment session unpleasant situation I looked out the window, Three year follow up Debbie wrote in her journal: This week in that is to say I just let it happen and didn’t Three years later, the therapist sent Debbie the train I was sitting reading a newspaper. assign any significance to it. That was such a an e-mail asking her how she was doing and There was a comic in it about vomiting. It was liberating feeling . how she would evaluate the value of the thera - a poster on the step (wat bedoel je hiermee? On A week later Debbie wrote: After a birthday py from her current situation. Debby the step?), at least that is how it was drawn. I party with a barbecue, I left early. I had a split - answered: I’m still not entirely happy when I did not immediately react with fear! Wow! I ting headache. Later on my husband came see someone vomit, but the violent panic reac -

[page 12 ] [Mental Illness 2012; 4:e3] Case Report tion doesn’t happen. And that’s so nice! were also present during the event. In this way, phobia. Am J Clin Hypn 1979:21:293-6. Meanwhile I switched jobs. Nowadays, I work the fear is, as it were, kept alive. The treatment 10. Wijesinghe B. A vomiting phobia overcome at an undertaker’s business. If I get a notifica - hypothesis for EMDR is that when the strength by one session of flooding with hypnosis. J tion of death, I go directly to the family and of such memories is weakened, and therefore Behav Ther Exp Psy 1974;5:169-70. then do the last operations. I can tell you: it’s the subject feels less emotionally charged, fear 11. Dattilio FM. Emetic Exposure and not always fresh and it often happens that some and associated avoidance behavior can also Desensitization Procedures in the Reduc- comes out through the mouth. I am really decrease or disappear. tion of Nausea and a Fear of Emesis. amazed at myself for doing this! Interestingly, in Debbie’s case, the memo - Clinical Case Studies 2003;2:199-210. ries that were selected as targets for subse - 12. McFayden M, Wyness J. You don’t have to quent processing proved not only to be memo - be sick to be a behaviour therapist but it ries involving loss of control ( powerlessness ), can help: treatment of a vomit phobic. Discussion but also to relate to self-worth. It would seem Behav Psychother 1983;11:173-6. that such events ( e.g. upsetting humiliations 13. Moran DJ, O’ Brien RM. Competence This paper presents a case in which EMDR and other embarrassing experiences) could imagery: a case study treating emetopho - was used successfully in the treatment of eme - have made Debbie vulnerable to the develop - bia. Psychol Rep 2005;96:635-6. tophobia. Although cognitive-behavioral thera - ment of fear and avoidance behavior following 14. Kahana SY, Feeny NC. Cognitive behav - py (CBT) has been proven to be efficacious for an encounter with a potentially traumatic or ioral treatment of health-related anxiety in treatment of specific phobias in general, 32-33 distressing event. A trauma-focused approach youth: A case example. Cogn Behav Pract positive treatment effects in case of treating predicts that targeting memories of such 2005;12:290-300. emetophobia are limited to a very small num - events would lead to symptom improvement. 15. Veale D. Cognitive behaviour therapy for a ber of case studies. Indeed, the treatment result reached beyond a specific phobia of vomiting. The Cognitive The result of the present case study is in decrease in Debbie’s fear of vomiting per se . Behaviour Therapist 2009;2:272-88. line with previous studies on fear and phobias After therapy, Debbie was not only better able 16. National Collaborating Centre for Mental with people suffering from debilitating fears to control situations in which she encountered Health. Post-traumatic stress disorder: that have developed following disturbing cues related to vomiting, but she also felt more The management of PTSD in adults and events in which a trauma focused approach able to stand up for herself much more than in children in primary and secondary care. has proven to be a useful treatment, compara - the past. Clinical Guideline 26. National Institute bly as effective as CBT. 21,34 An important differ - for Clinical Excellence, London, 2005. ence with the latter approach is that, in the 17. Bisson JI, Ehlers A, Matthews R, et al. present case study, the client was not system - Psychological treatments for chronic post - atically exposed to situations that she has so References traumatic stress disorder. Systematic far been avoiding ( e.g. sick people, TV pro - review and meta-analysis. Br J Psychiatry grams, vomit), but the therapy was aimed at 1. Hunter PV, Antony MM. Cognitive-behav - 2007;190:97-104. processing a series of memories of past events ioral treatment of emetophobia: The role 18. De Jongh A, Ten Broeke E, Renssen MR. which were considered to be crucial with of interoceptive exposure. Cogn Behav Treatment of specific phobias with eye regard to the origins and maintenance of her Pract 2009;16:84-91. movement desensitization and reprocess - symptoms. These beneficial effects of EMDR 2. Becker ES, Rinck M, Türke V, et al. ing (EMDR): Protocol, empirical status, should be considered in the light of the work - Epidemiology of specific phobia subtypes: and conceptual issues. J Anxiety Disord ing memory account explanation of this findings from the Dresden Mental Health 1999;13:69-85. approach. 31 There is a wide array of experi - Study. Eur Psychiat 2007;22:69-74. 19. De Jongh A, Ten Broeke E. Treatment of mental studies demonstrating that the vivid - 3. Philips HC. Return of fear in the treatment specific phobias with EMDR: Conceptua- ness and the disturbance of memories can rel - of a fear of vomiting. Behav Res Ther 1985; lization and strategies for the selection of atively easily be reduced using a variety of 23:45-53. appropriate memories. Journal of EMDR tasks that tax working memory. 28,29,35 One 4. van Hout WJPJ, Bouman TK. Clinical Practice and Research 2007;1:46-57. might postulate that memories that are less Features, Prevalence and Psychiatric Com- 20. De Jongh A, Van den Oord HJM, Ten emotional can be assimilated more easily into plaints in Subjects with Fear of Vomiting. Broeke E. Efficacy of Eye Movement semantic memory networks leaving more room Clin Psychol Psychother. In press. DOI: Desensitization and Reprocessing for functional interpretations. 10.1002/cpp.761. (EMDR) in the treatment of specific pho - What the present case study also illustrates 5. American Psychiatric Association. Diagno- bias: Four single-case studies on dental is how exposure to distressing or otherwise stic and statistical manual of mental disor - phobia. J Clin Psychol 2002;58:1489-503. aversive situations can lay down the ground - ders (DSM-TR) Washington DC, USA, 21. De Jongh A, Holmshaw M, Carswell W, van work for phobic conditions like emetophobia. American Psychiatric Association, 2000. Wijk A. Usefulness of a trauma-focused This agrees well with the data of a survey 6. Lipsitz JD, Fyer AJ, Paterniti A, Klein DF. treatment approach for travel phobia. Clin among emetophobics showing that about one- Emetophobia: Preliminary results of an Psychol Psychother 2011;18:124-37. third of them reported past memories of actual internet survey. Depress Anxiety 2001;14: 22. De Jongh A, Ten Broeke E. (1994). vomiting, and more than half had observed 149-52. Opmerkelijke veranderingen na één zit - someone else vomiting. 6 It is conceivable that, 7. Veale D, Lambrou C. The psychopathology ting met Eye Movement Desensitization at the moment one is confronted with situa - of vomit phobia. Behav Cogn Psychoth and Reprocessing: Remarkable changes tions that are similar to the earlier event, 2006;34:139-50. after one session of EMDR: Fear of nausea these, and perhaps other memories associated 8. Lydiard RB, Laraia MT, Howell EF, and vomiting. Tijdschrift voor Directieve with nausea, are more or less automatically Ballenger JC. Can panic disorder present Therapie en Hypnose 1994;14:89-101. activated and are re-experienced as if they are as irritable bowel syndrome? J Clin Psy- 23. Sheehan DV, Lecrubier Y, Sheehan KH, et about to be repeated. The same applies for the chiat 1986;47:470-3. al. The Mini-International Neuropsychia- thoughts, emotions and bodily sensations that 9. Ritow JK. Brief treatment of a vomiting tric Interview (MINI): the development

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