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Emetophobia in Youth: How Comprehensive Conceptualization Guides Effective Treatment Anxiety and Depression Journal Open Access Short Review Emetophobia in Youth: How Comprehensive Conceptualization Guides Effective Treatment Mary K. Plisco * Department of Anxiety and Depression, Richmont Graduate University, USA A R T I C L E I N F O A B S T R A C T Article history: Received: 19 July 2018 Emetophobia consists of an anxiety disorder characterized by the marked Accepted: 22 August 2018 Published: 25 August 2018 fear about specific objects or situations that may lead to vomiting. Keywords: Epidemiological studies have reported prevalence rates ranging from 0.1% to Fear of vomiting; Developmental; 8%, and youth who are untreated experience a chronic and fluctuating course Conceptualization; Treatment; Family characterized by significant impairments in functioning, including increased family conflict, disruptions to academic participation, and interference with Copyright: © 2018 Plisco MK et al., social interactions. Additionally, avoidance behaviors associated with Anxiety Depress J This is an open access article distributed emetophobia can lead to deficits in nutritional intake that may negatively under the Creative Commons Attribution License, which permits unrestricted use, affect child and adolescent physical development. It is important that clinicians distribution, and reproduction in any medium, provided the original work is are aware of the multiple factors that play a role in the development and properly cited. maintenance of the problem. Incorporating developmental, motivational, and Citation this article: Plisco MK. family-based theoretical frameworks into the established cognitive behavioral Emetophobia in Youth: How Comprehensive Conceptualization Guides Effective model for treatment of emetophobia will enhance treatment outcome. Treatment. Anxiety Depress J. 2018; 2(1):115. Introduction Emetophobia, or specific fear of vomiting, is an anxiety disorder characterized by the marked fear about specific objects or situations that may lead to vomiting as well as avoidance and/or distressing endurance of the objects and situations [1]. Epidemiological studies have reported prevalence rates ranging from 0.1% to 8% [2-4], and individuals who are untreated experience a chronic and fluctuating course characterized by significant impairments in physical, social, family, and academic functioning [5]. Because avoidance of food intake is a common symptom, individuals may experience weight loss and medical complications (e.g., metabolic concerns, vitamin deficiencies), which can be particularly problematic for youth, whose bodies are in a significant period of growth and development. Social impairment associated with emetophobia in children can be manifested in multiple ways, including through the loss of social interaction during mealtimes (e.g., avoiding school cafeteria, birthday parties, restaurants, sleepovers) and the negative social and emotional Correspondence: experience of getting bullied because of the fear (e.g., getting food thrown at Mary K Plisco, them). Furthermore, the disorder typically results in the increased family Department of Anxiety and Depression, Richmont Graduate tension associated with parent-child disagreements and frustrations about University, USA, Tel: 404-835- food intake. 6135; Fax: 404-239-9460; Email: [email protected] Emetophobia in Youth: How Comprehensive Conceptualization Guides Effective Treatment. Anxiety Depress J. 2018; 2(1):115. Anxiety and Depression Journal Clinical presentation often occurs after an incident in food items, may seek reassurance from parents or food which the individual has vomited or witnessed others providers about the safety of a food, or may vomiting. Case reports have highlighted numerous investigate/smell the food to check for its freshness. triggering situations for the disorder, including Additionally, there can be hypervigilance and prolonged emesis, acute appendicitis, roller coasters, associated checking of bodily symptoms that may be hospitals, dentist offices, being around intoxicated associated with vomiting, such as taking one’s people, pregnancy, and eating in public restaurants temperature. Finally, the child with emetophobia can [2,6-8]. Onset typically occurs before puberty [2]. engage in health promoting behaviors in an excessive Research has indicated that individuals with and maladaptive way. For example, individuals may emetophobia are more likely to have other comorbid engage in excessive hand washing or over-cleaning of anxiety and depressive disorders, including generalized foods. Although all of these behaviors provide an anxiety disorder, major depressive disorder, panic immediate sense of relief, they actually exacerbate the disorder, social anxiety disorder, and obsessive- symptoms over time through the process of negative compulsive disorder [9]. reinforcement. Unfortunately as a result, the more Conceptualization checking and excessive washing that the individual The conceptualization of emetophobia involves an engages in, the more frequent the intrusive worry about understanding of how the cognitive, behavioral, vomiting become. physiological, developmental, and family systems Cognitively, children develop expectations concerning interact to perpetuate the fear. Oftentimes, individuals feared stimuli, and they oftentimes experience with emetophobia can trace the development of the fear anticipatory anxiety related to the thoughts or images back to a significant event (either experienced or associated with eating. As such, simply thinking about a observed) involving vomiting or choking [10]. Thus, feared stimulus can result in the experience of anxiety classical conditioning can help to explain the [11]. Additionally, cognitive distortions about feared development of the fear, as vomiting (a naturally stimuli may develop, such that foods (and other feared distressing event) is paired with neutral stimuli (e.g., stimuli) are erroneously and/or exaggeratedly particular foods, restaurants, and eating situations). In associated with harm [2]. For example, common response to the conditioned fear, the child learns to cognitive distortions include: “Food has to be overcooked avoid stimuli associated with vomiting, and the child’s to be safe,” “Food that looks weird or is unfamiliar is not behavioral response (i.e., avoidance/escape) becomes safe,” “I will only stay healthy if I avoid [feared food, negatively reinforced through operant conditioning. situations, or people]”, and “Throwing up is unbearable Over time, the avoidance response can become and to be avoided at all costs.” generalized to many different food-related objects and Physiologically, the experience of anxiety is associated situations. Commonly avoided stimuli include: (1) foods, with a cascade of reactions directed by the limbic such as meat, dairy, eggs, and seafood, (2) situations, system. These reactions are experienced as such as restaurants, school cafeteria, and grocery stores, uncomfortable and distressing. Of note, a particularly and (3) people, such as health care providers, young uncomfortable symptom is nausea, as the child often children, and food servers [2]. interprets this physiological reaction as an indicator that In addition to behavioral avoidance, youth with he or she may vomit. The misinterpretation of these emetophobia also tend to engage in behaviors that are physiological symptoms facilitates an increase in anxiety aimed at enhancing one’s sense of protection from and leads to an enhanced avoidance response, thereby vomiting and/or checking to ensure one’s health [2]. exacerbating the cycle [8]. Other common physiological Children may feel the urge to check expiration dates on responses include sweating, trembling/shaking, Emetophobia in Youth: How Comprehensive Conceptualization Guides Effective Treatment. Anxiety Depress J. 2018; 2(1):115. Anxiety and Depression Journal accelerated heart rate, feeling faint or lightheaded, and emotional expression generates added tension that is cramping. experienced by the whole family, and this increased There are many important developmental considerations strain can further exacerbate symptoms [17]. to consider when comprehensively conceptualizing Another developmental issue to consider is the onset of symptom exacerbation. Parental accommodation of puberty, as females in particular may experience symptoms occurs when, in order to reduce their child’s symptoms of bloating and abdominal distress associated distress around eating, parents tend to provide with menstruation [18]. Children with emetophobia may modifications that allow for short term relief but misinterpret these symptoms to be signs of the potential unintentionally prolong and worsen symptoms [12]. for vomiting, and thus may experience anxiety. As a Examples of parental accommodation include refraining result, they may avoid eating during this time period, from going out to eat, preparing foods in ritualistic which can result in low energy and fatigue, and in ways, or substituting soft foods for more challenging extreme form, weight loss and associated amenorrhea. food textures [13]. Parents may comply with demands A final complicating developmental factor concerns for reassurance through telling the child that food is safe motivational issues surrounding treatment, as children or fresh. Additionally, parents may reinforce the rarely refer themselves to treatment, often do not avoidance behaviors through allowing children to miss acknowledge the existence of problems, and may be at school or other food-related events, such as
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