20091027-5

20091027-4

SOURCE: American Psychological Association | PHOTO: iStockphoto | GRAPHIC: The Washington Post

GoogleNews.com, Washington Post, by Lindsay Tanner  —  Groundbreaking research suggests genes help explain why some people can recover from a traumatic event while others suffer post-traumatic stress disorder. Though preliminary, the study provides insight into a condition expected to strike increasing numbers of military veterans returning from combat in Iraq and Afghanistan, one health expert said.

Researchers found that specific variations in a stress-related gene appeared to be influenced by trauma at a young age _ in this case child abuse. That interaction strongly increased the chances for adult survivors of abuse to develop signs of PTSD.

Among adult survivors of severe child abuse, those with the specific gene variations scored more than twice as high (31) on a scale of post-traumatic stress, compared with those without the variations (13).

The worse the abuse, the stronger the risk in people with those gene variations.

The study of 900 adults is among the first to show that genes can be influenced by outside, nongenetic factors to trigger signs of PTSD. It is the largest of just two reports to show molecular evidence of a genetic influence on PTSD.

“We have known for over a decade, from twin studies, that genetic factors play a role in vulnerability to developing PTSD, but have had little success in identifying specific genetic variants that increase risk of the disorder,” said Karestan Koenen, a Harvard psychologist doing similar research. She was not involved in the new study.

The results suggest that there are critical periods in childhood when the brain is vulnerable “to outside influences that can shape the developing stress-response system,” said Emory University researcher and study co-author Dr. Kerry Ressler.

The study appears in Wednesday’s Journal of the American Medical Association. Several study authors, including Ressler, reported having financial ties to makers of psychiatric drugs.

Ressler noted that there are probably many other gene variants that contribute to risks for PTSD, and others may be more strongly linked to the disorder than the ones the researchers focused on.

Still, he and outside experts said the study is important and that similar advances could lead to tests that will help identify who’s most at risk. Treatments including psychotherapy and psychiatric drugs could be targeted to those people, Ressler said.

About a quarter of a million Americans will develop PTSD at some point in their lives after being victimized or witnessing violence or other traumatic events. Rates are much higher in war veterans and people living in high-crime areas.

Symptoms can develop long after the event and usually include recurrent terrifying recollections of the trauma. Sufferers often have debilitating anxiety, irritability, insomnia and other signs of stress.

Dr. Thomas Insel, director of the National Institute of Mental Health, said the study is particularly valuable for the light it sheds on military veterans, who are known to be vulnerable to PTSD.

He said the results help explain differences in how two people see the same roadside bomb blast. One simply experiences it as “a bad day but goes back and is able to function.” The other later develops paralyzing stress symptoms.

“This could be quite a wave that will hit us over the months and years ahead,” Insel said. His agency paid for the study.

Study participants were mostly low-income black adults, aged 40 on average, who sought non-psychiatric health care at a public hospital in Atlanta. They were asked about experiences in childhood and as adults and gave saliva samples that underwent genetic testing.

Almost 30 percent of participants reported having been sexually or physically abused as children. Most also had experienced trauma as adults, including rape, attacks with weapons and other violence.

Researchers focused on symptoms of PTSD rather than an actual diagnosis, and found that about 25 percent had stress symptoms severe enough to meet criteria for the disorder, Ressler said.

Childhood abuse and adult trauma each increased risks for PTSD symptoms in adulthood. But the most severe symptoms occurred in the 30 percent of child abuse survivors who had variations in the stress gene.

Researchers were not able to determine if the symptoms were reactions to the child abuse or to the more recent trauma _ or both, said co-author Rebekah Bradley, also of Emory University.

The study is an important contribution to a growing body of research showing how severe abuse early in life can have profound, lasting effects, said Duke University psychiatry expert John Fairbank, co-director of the National Center for Child Traumatic Stress. He was not involved in the research.

http://jama.ama-assn.org/cgi/content/abstract/302/15/1651
JAMA – Vol 302, Number 15, October 21, 2009

A Randomized Controlled Trial

Robert M. Carney, PhD; Kenneth E. Freedland, PhD; Eugene H. Rubin, MD, PhD; Michael W. Rich, MD; Brian C. Steinmeyer, MS; William S. Harris, PhD

JAMA. 2009;302(15):1651-1657.

Context  Studies of depressed psychiatric patients have shown that antidepressant efficacy can be increased by augmentation with omega-3 fatty acids.

Objective  To determine whether omega-3 improves the response to sertraline in patients with major depression and coronary heart disease (CHD).

Design, Setting, and Participants  Randomized controlled trial. Between May 2005 and December 2008, 122 patients in St Louis, Missouri, with major depression and CHD were randomized.

Interventions  After a 2-week run-in period, all patients were given 50 mg/d of sertraline and randomized in double-blind fashion to receive 2 g/d of omega-3 acid ethyl esters (930 mg of eicosapentaenoic acid [EPA] and 750 mg of docosahexaenoic acid [DHA]) (n=62) or to corn oil placebo capsules (n=60) for 10 weeks.

Main Outcome Measures  Scores on the Beck Depression Inventory (BDI-II) and the Hamilton Rating Scale for Depression (HAM-D).

Results  Adherence to the medication regimen was 97% or more in both groups for both medications. There were no differences in weekly BDI-II scores (treatment x time interaction = 0.02; 95% confidence interval [CI], -0.33 to 0.36; t112 = 0.11; P = .91), pre-post BDI-II scores (placebo, 14.8 vs omega-3, 16.1; 95% difference-in-means CI, -4.5 to 2.0; t116 = -0.77; P = .44), or HAM-D scores (placebo, 9.4 vs omega-3, 9.3; 95% difference-in-means CI, -2.2 to 2.4; t115 = 0.12; P = .90). The groups did not differ on predefined indicators of depression remission (BDI-II 8: placebo, 27.4% vs omega-3, 28.3%; odds ratio [OR], 0.96; 95% CI, 0.43-2.15; t113 = -0.11; P = .91) or response (>50% reduction in BDI-II from baseline: placebo, 49.0% vs omega-3, 47.7%; OR, 1.06; 95% CI, 0.51-2.19; t112 = 0.15; P = .88).

Conclusions  Treatment of patients with CHD and major depression with sertraline and omega-3 fatty acids did not result in superior depression outcomes at 10 weeks, compared with sertraline and placebo. Whether higher doses of omega-3 or sertraline, a different ratio of EPA to DHA, longer treatment, or omega-3 monotherapy can improve depression in patients with CHD remains to be determined.

Trial Registration  clinicaltrials.gov Identifier: NCT00116857
Author Affiliations: Departments of Psychiatry (Drs Carney, Freedland, and Rubin and Mr Steinmeyer) and Medicine (Dr Rich), Washington University School of Medicine, St Louis, Missouri; and Cardiovascular Health Research Center, Sanford Research, University of South Dakota, Sioux Falls (Dr Harris).

20091027-3

Hayden Newell of Boones Mill, Va., was rushed to a hospital three times before doctors were able to determine the cause of his severe and unpredictable allergic reactions. (Stephanie Klein-Davis – For The Washington Post)

 

Research Sheds Light on Dangerous Allergic Reactions

The Washington Post, by Sandra G. Boodman, October 2009  —  This cannot be happening again, Hayden Newell thought as the angry, red, ferociously itchy welts encircled his waist and spread up his arms. The 57-year-old metallurgist from tiny Boones Mill, Va., who was attending a business lunch in Florida, knew what would probably happen next: His lips would grow numb, making it hard to speak, he would become short of breath and his blood pressure would plummet: all unmistakable signs of anaphylaxis, a potentially fatal allergic reaction. Newell knew from experience that he had to get to an emergency room — fast.

The same thing had happened a month earlier, in August 2008, an event that culminated in an early-morning ambulance ride to a hospital in Roanoke. At the time, his general practitioner suspected that Newell had developed an allergy to the oysters he had eaten the previous night. But tests revealed no shellfish allergy, so Newell had grazed at a buffet, sampling shrimp, scallops and meatballs.

What, he wondered, as a colleague drove him to a Florida ER, could be causing these frightening episodes that came out of nowhere?

The probable answer did not emerge until nearly six months later, and it seemed downright bizarre. The diagnosis, shared by a growing number of patients on two continents and described in two recent studies, has upended long-held views about an allergy previously considered rare.

“It has changed our thinking,” said Newell’s allergist, Saju Eapen of Roanoke.”This was not something we looked for in the past.”

* * *

In July 2008, Newell spent several days visiting his nephew in rural North Carolina. Three days after returning home he noticed a red spot between two toes on his left foot, evidence of a tick he had picked up while walking barefoot in the country. He extracted it and, assuming the bite had become infected, called his doctor, who prescribed an antibiotic.

Problem solved, Newell thought.

But a month later, hours after a dinner that included oysters Rockefeller and filet mignon, both of which he had eaten many times before, Newell awoke at 3 a.m. to discover that his chest and waist were blanketed by itchy hives.

“I wasn’t sure what was going on,” Newell said, so he got up and took a shower, increasingly alarmed by the huge, spreading welts. “I got into bed and tried to relax until morning.”

At 7 a.m., while driving to his general practitioner’s office, Newell realized his lips felt numb. He sat in the empty waiting room, hoping the doctor would arrive soon, while he could still talk. Instead, the nurse took one look at him, he recalled, and said, “You’re having anaphylactic shock. We need to get you to a hospital right away.” She called 911, and Newell was whisked by ambulance to a nearby ER, where he was given Ben-adryl and other drugs to counteract the severe allergic reaction. His doctor, thinking he might be allergic to oysters, sent him to Eapen.

The allergist performed skin tests and took blood samples, warning Newell to stay away from shellfish. A few weeks later, after tests found nothing, he was told it was safe to eat seafood. The next month was the fateful Florida buffet. This time, the hives appeared more quickly, in less than an hour.

“I figured, it’s got to be some kind of seafood,” said Newell, who this time had eaten crab and scallops, but not oysters.

Eapen said that at this point he wasn’t sure whether Newell was suffering from a true anaphylactic reaction or chronic hives, which can cause anxiety and shortness of breath. He prescribed an EpiPen, a device that administers an emergency epinephrine injection, which he told Newell to carry at all times. Then he handed him an order for a blood test. In the event of another attack, he told Newell, doctors should test his blood for levels of serum tryptase within three hours. An elevated reading would indicate true anaphylaxis, not just anxiety.

Newell didn’t have to wait long. In December, after eating chicken and beef — but not seafood — he was driving home from a business lunch in Norfolk when he felt the unnerving itching.

“I was thinking, ‘I won’t be able to eat anything,’ ” as he pulled off the highway and headed for the nearest hospital, he recalled. The episode did lead to one definitive answer: His serum tryptase level was elevated, which meant the anaphylaxis was genuine. But what was he so violently allergic to?

At an appointment the following day, Eapen asked a crucial question: “Do you remember if you had beef when you had shellfish?” The answer, Newell said, was yes, every time.

Eapen said he thought knew what was wrong. When the allergist asked about tick bites, Newell told him about the July incident.

Eapen took a blood sample and told Newell he was sending it to a lab at the University of Virginia School of Medicine for testing that might point to the suspected culprit: an allergy to red meat. Eapen was familiar with groundbreaking work underway at U-Va.’s allergy clinic that had found a link between a reaction to tick bites and the development of a sudden allergy to red meat, as well as pork and lamb, in people who had eaten it all their lives without incident.

A team headed by U-Va.’s Thomas Platts-Mills, an internationally prominent allergist, published a study in February detailing the cases of 24 adults who developed a sudden allergy to red meat. Eighty percent had reported being bitten by ticks weeks or months before the allergy appeared, and many had experienced anaphylaxis as much as six hours after eating red meat, a highly unusual occurrence because food allergies typically cause violent reactions within minutes.

Similar findings were reported in the Medical Journal of Australia in May by a team of Sydney allergists.

So how does a tick bite trigger a sudden allergy to meat?

Scott Commins, an assistant professor of medicine and lead author of the U-Va. study published in the Journal of Allergy and Clinical Immunology, said that in susceptible people such as Newell, a tick bite that causes a significant skin reaction seems to trigger the production of an antibody that binds to a sugar present on meat called alpha-galactosidase, also known as alpha-gal. When a person who has the antibody eats meat, it triggers the release of histamine, which causes the allergic symptoms: hives, itching and, in the worst case, anaphylaxis.

But many questions remain unanswered, said Platts-Mills, whose research is continuing. His lab has collected data on more than 300 patients from across the country and abroad.

“We’re sure ticks can do this,” he said. “We’re not sure they’re the only cause.” Nor do researchers know why anaphylaxis is so delayed or why only some people develop a problem after tick bites. They do know that the allergic reaction is dose-related: Eating a tiny amount of meat probably won’t cause a serious reaction. A large steak will.

Commins said researchers have also observed that people with certain blood types appear to be more at risk. Those with the rarest types — B and AB — do not appear vulnerable, because their blood is chemically similar to alpha-gal.

Climate appears to play a role: Blood samples from Boston and Scandinavia almost never reveal alpha-gal antibodies, which are common in samples from patients in Virginia, North Carolina and other parts of the South, as well as parts of Australia.

Testing of Newell’s O-positive blood in Platts-Mills’s lab revealed very high levels of alpha-gal, and other tests confirmed that after more than a half-century of eating meat, he now had an untreatable allergy. Newell is now enrolled in a large allergy study at U-Va.

Eapen can’t advise Newell — or the 30 or so other patients in his practice found to have a meat allergy — to do much except avoid red meat, lamb and pork.

An enthusiastic cook, Newell said he misses making and eating his favorite dishes: beef bourguignon and beef Bolognese. The biggest problem, he said, is avoiding meat at business lunches, which often take place in steakhouses.

“It’s probably better for me in the long run,” Newell said wistfully, “but I’d still like a nice steak occasionally.”

20091027-1

GoogleNews.com, Washington Post, by Jennifer LaRue Huget, October 26, 2009  —     If you are an emetophobe, you’ve probably been trying hard to avoid watching (or even listening to) the footage of young Falcon Heene, the boy who didn’t get in that helium balloon, tossing his cookies during his family’s interview on Good Morning America.

Even for those of us who don’t have an irrational fear of vomiting or of witnessing others as they lose their lunch, the scene’s pretty wrenching and may make us feel like hurling. But for an emetophobe (emesis = vomiting, phobe = fear), just the thought of watching a kid or anyone else vomit is terrifying to the core.

Though it’s thought to be among the more common phobias, emetophobia’s been little studied, so we don’t know much about what causes it or how to fix it. One study showed that it tends to take hold early– around age 9 –and to last a long time (a mean duration of 22 years). Emetophobes– or, as some apparently call themselves, emets– may avoid going out much for fear they’ll puke in public or see someone else do so. They may become picky eaters, avoiding anything they think might make them sick. And, according to D.C. psychotherapist Jerilyn Ross, who has treated a number of people with fear of vomiting, some women even put off getting pregnant because they so dread the idea of morning sickness– and worry that they might not be able to care for their children if such care involved overseeing upchucking.

Ross says that while none of us particularly relishes vomiting or seeing others do so, that distaste is rational. But when the fear of vomiting is so severe it makes a person rearrange his activities– even if he’s never had a bad experience involving vomit, as Ross says is usually the case– it crosses the line to become a phobia. She says that as with many phobias, emetophobia is more a fear of the fear of vomiting than of the act itself.

Ross predicts that many emetophobic people will read this blog and feel relief at learning they’re not alone. She wants them to know that not only are they not alone, but their phobia can be treated; common approaches include exposure therapy, in which patients are gradually, gently desensitized to the object of their fear. They may, for instance, work their way up from being able to be in the same room with a joke-shop rubber vomit clump to watching a movie in which someone vomits. Some patients may also need anti-anxiety medications.

People with an extreme fear of vomiting “shouldn’t have to live secretly and privately,” Ross says. Why not start here? Do you worry irrationally about getting sick or seeing someone else get sick? How does that affect your life?

FAQs

Q. What is emetophobia?

A. Emetophobia is an irrational or excessive fear of vomiting.

Q. But nobody likes to vomit.

A. A phobia is distinguished from an ordinary fear by the irrational and excessive anxiety caused by the stimuli for the phobic individual. For example, many people would not want to explore caves because of a fear of snakes. But some people with a snake phobia, called ophidiophobia, are afraid to walk on the sidewalk in downtown Chicago because a snake might be there. So, hundreds of millions of people may fear vomiting, but they don’t alter their daily lives because of it the way emetophobics do.

The fear is also all-consuming; for most emetophobics, vomiting is their single worst fear. In casual conversation, many phobics say they’d rather die than vomit. (We hope that’s overstated.) It’s not an overstatement that for many phobics, anxiety about vomiting ruins almost every day.

There is another phobia related to emetophobia called social phobia. (Social phobia is a general fear of being judged by other people.) People who are social phobic often have a fear of vomiting in public, but this is not the same as emetophobia. People with social phobia vomit in private with no more anxiety than a normal person would have. (Of course, emetophobics fear vomiting in public at least as much as social phobics do. And some people have both emetophobia and social phobia.) Social phobics make sure they can get to a bathroom if they need to vomit (and this can go to an extreme as well, like insisting on an aisle seat in crowded places), but they don’t do all the things that emetophobics do.

Q. What things do emetophobics do?

A. Dietary restrictions are universal among emetophobics. Most emetophobics have a list of foods they won’t eat because they suspect them of being likely carriers of food poisoning; many avoid other foods because they associate them with a childhood episode of vomiting. Some of the foods emetophobics avoid have no obvious relation to either of those. Since most food poisoning is caused by unsanitary preparation rather than tainted food, phobics are roundly meticulously hygenic cooks. (Easiest way to lose an emetophobic? Lick the spoon while cooking.) Ironically, emetophobics are sometimes suspected by others of having eating disorders.

Q. But isn’t emetophobia a kind of eating disorder?

A. Not really. A person with even severe emetophobia will generally eat enough to stay healthy, although it is not unheard of for emetophobics to be hospitalized for malnutrition. This is different from anorexia nervosa inasmuch as the emetophobic is not particularly concerned about weight gain or loss.

Q. What other things do emetophobics do?

A. At the grocery store, the emetophobic may verge on obsessive-compulsive, carefully examining each of a dozen oranges going into the bag (they might actually wash those oranges before eating them too); reaching back in the cooler to get “colder” items; hounding the deli personnel for certain items to be selected or cut; and our favorite, hand-washing following a visit to the meat department.

It is not unusual for emetophobics to have a particularly stringent set of criteria for eating out. Some avoid restaurants altogether. Some will order an entree but will never eat from a buffet or salad bar. Some claim to have a 6th sense that tells them not to eat in a particular restaurant. Some emetophobics are uneasy being in public places, especially restaurants, because they are afraid that other people will vomit. Some will go hungry rather than eat in public places.

Besides eating habits, emetophobia affects the lives of its sufferers in many ways. Many female emetophobics shun pregnancy because they fear morning sickness and other vomiting that frequently happen during pregnancy.

Here are two facts sure to be heartening to an emetophobic woman of childbearing age: Nearly all emetophobics who are mothers report surviving pregnancy without vomiting. So do 23 percent of non-emetophobics.

Others stay away from children altogether due to the fact that children become ill more often than most adults. Nearly all emetophobics report being unable to care for their children and other family members when those people fall ill. Some will sleep in another room when a family member is ill. One phobic reports sleeping with the window open in winter in an effort to kill the virus. Some even fear catching illness from animals, making pets an uneasy choice for them.

A good many emetophobics avoid travel, especially to foreign countries. (Some emetophobics report vomit-free foreign vacations.) Nearly all emetophobics avoid water travel; some refuse to fly as well, and a few even stay out of land vehicles. (Others insist on being the driver. This has a legitimate basis, as it is nearly impossible for a driver to become carsick.) Of course, few emetophobics will get on amusement rides.

Although more common in children, emetophobics frequently have superstitions about their trigger event or subsequent times they vomited. These can include avoiding the pajamas they were wearing when they vomited or even the same color pajamas; refusing to drink out of a color of cup they drank from before they vomited; being anxious even about the day of the week they vomited, or the month, even blocking out pleasant memories of a year in which they vomited; avoiding music that was popular at the time; etc. Even the children who do these things understand that these totems are completely unrelated to vomiting; these behaviors serve to illustrate the irrational nature of the phobia.

Many emetophobics exclude themselves from social activities, and some of these report that the social restriction is one of the worst things about the phobia. They’re afraid to go to places where people may be drunk, and so avoid parties, pubs and other social occasions. Many are afraid in the theatre, the movies, sporting events, and other places where crowds gather.

Emetophobia affects career choice as well, with many otherwise-qualified (and perhaps even interested), intelligent sufferers eschewing fields that they see as high-risk for vomiting, such as health care, the military, teaching, laboratory research, aviation, and space.

Q. How did emetophobics get that way?

A. Nearly every case of emetophobia was triggered by a particularly traumatic episode of vomiting that occurred between the ages of 6 and 10. Most of these incidents came on unexpectedly. After the frightening emetic incident, most phobics were very careful to avoid vomiting. If they experienced it at all, it was with a tremendous amount of fear and anxiety. So they never came to experience vomiting as something normal or routine. Some emetophobics say their parents were not supportive of them when they vomited as children, and some say that their parents even made them vomit. However, many emetophobics have no idea why they have this phobia.

Many people believe it’s an issue of control. Some say emetophobics want maximum control over their bodies, or that they are making up for a lack of control they had over situations as children. Some experts think that anxiety over separation from a parent or other loved one during childhood contributes to emetophobia. And some therapists, not emetophobics themselves, suggest a link to childhood sexual abuse. (The majority of emetophobics were not abused and even some who were doubt this connection.)

Q. Why do phobics fear vomiting?

A. For many phobics, vomiting is something unknown. They’re much like the child of three or four who has no recollection of ever vomiting. Most children vomit fairly regularly throughout childhood; they come to realize that it’s a rather routine happening for them and most other people. Not the emetophobic. They may have vomited as a small child, but then did not do so again until the episode that brought on their phobia. They never learned that vomiting is a normal part of life. But of course, for them, it never was.

Q. So what happens to emetophobics when they actually vomit?

A. The fact most surprising to non-phobics is that the great majority of emetophobics rarely, if ever, vomit. An emetophobic is a person who has been in car collisions more often than they have vomited. Most phobics can count the number of times they have vomited on the fingers of one hand. Some emetophobics have survived pregnancy and childbirth, appendicitis, and gall bladder operations without as much as a single retch. Even when they did, they typically had only a single episode of vomiting with each illness — 52 percent say they only vomit once during an illness — in contrast to many non-phobics who can attest to vomiting repeatedly over the course of an illness. (Only a third of non-phobics vomit only once in a typical illness.)

In a recent Internet survey, the average non-emetophobic reported having vomited most recently five months earlier. The median emetophobic most recently vomited 12 1/2 years earlier! In their entire lives, non-phobics claimed to have experienced a median 23.5 illnesses that caused them to vomit. For emetophobics, the figure was 6.5. (The average age in both groups was 29.4.)

Some phobics say the main reason they vomited is because they were so tired of feeling nauseated that they “gave in” and let themselves vomit. Many adult emetophobia sufferers can claim to have been vomit-free for 10 or 20 years or more. Phobics who have actually vomited since their trigger experience frequently say that they realized at the time that vomiting isn’t so bad, but they went back to fearing it later — often the very same day.

Fully two thirds of phobics say they don’t vomit until they decide to let it happen. Only 13 percent of non-phobics say this, 59 percent of them saying they fight nausea but vomiting happens anyway. 28 percent of non-phobics don’t fight nausea at all, something only 5 percent of phobics claim. Non-phobics on average let themselves vomit after feeling nauseated for only 21 minutes. No emetophobic was willing to “give in” in less than two hours, and some claimed being willing to endure nausea for five days!

Although they’re not apt to vomit, emetophobics can work themselves up into frenzies of anxiety or even actual nausea simply by being exposed to people with gastrointestinal trouble. At the merest suggestion that someone with whom they are breathing common air has a GI complaint, the emetophobic will get panicky. They will watch for symptoms which are all too easily psychosomatic. This tends to snowball as panic attacks get much worse as the phobic experiences real or imagined nausea.

One problem universal among emetophobes is an inability to distinguish nausea from normal gastrointestinal feelings. Here are some of the things people feel happening in their alimentary canals. They all feel different:

  • hunger
  • burping
  • stomach emptying
  • intestinal motility
  • intestinal gas
  • nausea
  • heartburn
  • acid reflux
  • rumination
  • stomach fullness
  • there are yet others!

The emetophobic at a young age failed to distinguish among these feelings and recognizes many non-emetic feelings as nausea. This is analagous to someone who hasn’t learned to distinguish “friendly” noises at night from noises to be concerned with. Many emetophobics acknowledge that what they report as nausea isn’t the same as what normal people mean when they say they have nausea. Despite this realization, which occurs on some level in almost every emetophobe, they continue to derive anxiety from their ordinary gastric feelings.

In a recent Internet survey, the average non-emetophobic reported feeling nauseated 15.6 times per year when they did not actually vomit. The average emetophobic reported nausea 119 times a year! This is due to a few emetophobics — these people who almost never vomit — reporting daily, and even constant, “nausea.”

Interestingly, 85 percent of phobics say vomiting is worse than nausea, but 63 percent of non-phobics say nausea is worse than vomiting.

Q. Why don’t emetophobics vomit very often?

A. The answer is not clear. Most emetophobics have great skill at fighting nausea. They will tell you that they felt very ill but lay down until the nausea passed. Some use prescription anti-nausea drugs like Tigan or Compazine. Others use tricks like ice cubes. Many try to bolster their immune systems through vitamins and herbal remedies. The most likely reason is this: Since these people became phobics because they had high thresholds for vomiting as children, they naturally should have been expected to have even higher thresholds as adults.

Different people experience illness in different ways. Some people who get gastroenteritis (often erroneously called “stomach flu”) or food poisoning tend to vomit. Others similarly infected will only have diarrhea. Emetophobics nearly always fall in the latter class. (Emetophobics don’t generally fear diarrhea, except by its association with vomiting.)

The average phobic vomited 3.6 times as the maximum during a single illness. For the average non-phobic, the figure is 7.9 times, or more than twice as much. Excluding a single high case, the figure for the phobics would be only 2.8 times.

A theory of emetophobics’ lack of vomiting can be deduced from the act itself. (To learn more about how vomiting happens, see the author’s Vomiting FAQ.) Essentially, when the body is ready to vomit, there are some key breathing movements that have to happen for vomiting to occur. Emetophobes — especially those past puberty — have usually developed enough control over their breathing that they can keep those final steps from happening, and thus they remain in the last stage of nausea until either they give up and vomit, or their brain gives up on trying to vomit and the nausea passes.

Q. What are some ways of controlling nausea?

A. The Doctors Book of Home Remedies has these suggestions: taking powdered ginger root; drinking only clear liquids or flat, warm 7-Up; eating some light carbohydrates, like crackers or toast; keeping the head still; distracting the mind from the nausea; applying accupressure to the wrist; and use of some over-the-counter preparations. (The book also suggests allowing yourself to vomit, an approach not often in vogue with emetophobics.)

Q. So what’s wrong with emetophobia? It sounds as if some people have found a way to never vomit.

A. The problem is that emetophobia consumes a great deal of the time and energy of the person who suffers from it. There is the constant mental stress of worrying when one will vomit next. It is a load that is never off the mind of the phobic. It is amazing that someone who has not had an emetic experience in 20 years can be unable to enjoy a meal because they fear vomiting. Frequently, the first item on the prayer list of a religious emetophobic is continued protection from the dreaded malady. Some emetophobics report spitting in the toilet after each use as an offering to the “vomit gods.”

Feeling jealous of people who never vomit?
Most emetophobics envy those who vomit regularly without anxiety.

Most phobics suffer terrible panic attacks when they have nausea or imagine that they do. These panic attacks are much worse for them than vomiting is for an ordinary person. Yet the act remains unthinkable.

The phobia interferes with educations, careers, marriages, and family relationships. Many phobics take time away from work or school unnecessarily because they fear either vomiting themselves or being exposed to people who can pass germs that will cause them to vomit. Many phobics suffer panic or anxiety attacks when they imagine the slightest hint that they may vomit. These attacks can be quite severe. Phobics exclude themselves from the activities mentioned above. All this can contribute to the development of other phobias such as agoraphobia and social phobia as well as other health problems like insomnia. (This is often because some emetophobics feel the only safe place from vomiting, or barring that, the only safe place to be if they can’t keep from vomiting, is home. This feeling can lead to isolation and even agoraphobia.)

Emetophobia can also hinder the social life of the sufferers because non-phobics can’t abide being friends with one whose obsession with vomiting is so ever-present. Needless to say, it’s a hindrance to courtship when an emetophobe (on the first date) asks questions like “Do you vomit often?”

Emetophobia can lead to bad eating habits as well; some sufferers’ unusual food intakes are perhaps not well balanced and nutritious; standard fare, perhaps only slightly more likely to cause food poisoning, would be considerably healthier. Most phobics abstain from any food that has ever caused them illness. Some even shun any foods that they ate and then vomited even if they believe the food was not to blame.

Emetophobics are usually incapacitated when it comes to taking care of sick family members. Some feel guilty that they are unable to be supportive of their children. Some fear their child is confused because the parent seems to be more worried about his or her potential illness than about the child’s actual illness.

One emetophobic adult tells the story about how she joined a sailing club with some other women. The club takes extended sailing voyages every year. Her first week out, the craft encountered bad weather, and the woman got seasick. She put her whole effort into keeping from vomiting (a successful effort, naturally), at a time when all hands were needed on deck. Only then did she tell her mates about her condition. Not surprisingly, she was expelled from the club, and outrageously, they made a rule that future initiates have to vomit in front of one of the others before being admitted, in order to prevent emetophobes from joining!

Q. Is there any cure for vomit phobia?

A. There isn’t a ready, out-of-the-box cure for emetophobia or any other phobia. Some people suggest desensitizing phobics to vomit. Densensitization supposedly culminates with the phobic inducing vomiting. But that isn’t the best option. This is because many phobics are already around vomiters (usually their children; additionally, phobic health care workers are exposed to their patients, and phobic teachers are exposed to their students). And as noted above, many phobics have vomited since developing their phobia, and it didn’t cure them. (To make matters worse, many phobics have anxiety about losing their 10 or 20 year records.)

Many psychiatrists prescribe pills for emetophobics. While pills may reduce symptoms of emetophobia (anxiety attacks, etc.), we are unaware of anyone being cured that way. Furthermore, pills come with side effects, sometimes including the dreaded event. Interestingly, while emetophobics, when asked what has caused them to vomit in their lives, reported excess alcohol consumption, motion sickness, pregnancy, food poisoning, and self-induced at rates lower than non-phobics reported, the rate for reaction to medications was higher.

While inducing vomiting doesn’t seem to be a viable option, we know of a few emetophobics who have been cured by natural vomiting. Their stories are told elsewhere on this website (see here). The difference between these cured emetophobes and others who experience vomiting and are not cured seems to be attitudinal. They seem to have approached impending vomiting not as a disaster, but as an opportunity to overcome their fear and anxiety. Following them as a model, an emetophobe would resolve (when not nauseated) that the next time they’re confronted with (true) nausea, they will let themselves vomit. As you can probably guess, few emetophobics make this resolution.

The next best solution is probably for phobics to gradually resume the activities they exclude themselves from. That way they can have their fear of vomiting, but it won’t interfere with their daily lives as much. Talking about it with other emetophobics seems to help these steps come more easily.

Try this exercise. Make a list of activities feared as potentially causing vomiting. Here’s an abstract list:

  • Riding the carousel at the carnival
  • Riding the tilt-a-whirl at the carnival
  • Eating undercooked chicken
  • Taking my daughter to the zoo
  • Riding a ferry across the harbor
  • Watching a vomit scene in a movie
  • Taking an ocean cruise
  • Going to family night at my children’s school
  • Going out for drinks with friends after work

Next, place the items on your list in order from least likely to cause vomiting to most likely to cause vomiting. Here’s the abstract list ordered this way:

  1. Watching a vomit scene in a movie
  2. Taking my daughter to the zoo
  3. Going to family night at my children’s school
  4. Going out for drinks with friends after work
  5. Riding the carousel at the carnival
  6. Riding a ferry across the harbor
  7. Riding the tilt-a-whirl at the carnival
  8. Taking an ocean cruise
  9. Eating undercooked chicken

Make an effort to do the item on your list numbered 1. Then, work up to number 2, and so on. It’s not necessary to do everything on the list. You might decide, quite correctly, that it’s not necessary to eat undercooked chicken to conquer your phobia.

Another thing that helps is developing new interests and activities which engage the mind, take time, and don’t cause anxiety about vomiting. Anything that gets phobics to take their minds off their fear is helpful.

Q. Who are these emetophobics? What should I do if I encounter one?

A. You wouldn’t know one if you saw one. The people who live with them sometimes have no idea.

Some emetophobics are secretive. Some fear that if they mention their lack of vomiting, it will “jinx” them. (Many emetophobics “knock wood” when they mention how long since their last vomit, especially in e-mail.) Others worry that revealing their fear would leave them in a vulnerable position. If one did “come out” to you, there is a good chance that the phobic is your significant other or a member of your family. (A few emetophobics report that everyone who knows them knows.) Be supportive. Try to understand their fear, but don’t try to reason them out of it. You’re better off putting up with their idiosyncrasies than forcing them to do things your way. They’ve had their fear for a long time. They might decide they’re more comfortable with it in their life than you.

As to who they are, it is clear that more women than men suffer from emetophobia. Even the non-scientific sample that answered the survey whose statistics are presented on this page makes that obvious. While the non-phobics who answered the survey were only slightly more likely to be female (59 percent), 83 percent of the phobics who answered the survey were female. The Internet discussion groups devoted to emetophobia are also an overwhelmingly female community. These numbers are all the more striking in light of how male-dominated the online world still is.

Emetophobics have answered the survey from every continent except Antarctica (which isn’t a choice on the form). They come in every color and from every walk of life. The oldest emetophobe to have answered the survey was 55, although older ones are known to exist. Folk singer Joan Baez and actress Denise Richards, and Today show host Matt Lauer have publicly acknowledged their emetophobia.

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Q. My group is taking a day cruise in the ocean soon, and I’m scared witless! I’ll just tell them I’m afraid of the water!

This begs the question, why is it acceptable to be afraid of the water but not to be afraid of vomiting?

The answer is more complex. It’s easier to manipulate people if you know they have emetophobia than if they have a fear of heights, for example. Emetophobics worry that someone will try to make them vomit, either in an attempt to “cure” them, or just out of spite. (We think anyone who would do that is downright evil!) Also, telling someone you have emetophobia will undoubtedly lead to a discussion of vomiting histories, something many emetophobics find dreadfully uncomfortable, notwithstanding their ability to win a bragging contest.

Q. Are emetophobics mentally healthy otherwise?

Most of them have no other psychological problem. A small minority of phobics experience their emetophobia as only one part of a large plate of other mental illnesses. This has been most evident in some of the discussion groups on the Internet.

Q. Does emetophobia run in families?

It is well established that phobias cluster in families. Perhaps the tendency to develop a phobia is what is actually inherited, and the emetophobic individual happens to attach this tendency to vomiting. The environmental cause of emetophobia is even more striking. Many emetophobics claim the lack of support from their parents during childhood vomiting episodes precipitated their phobia. It would not be surprising to find that an emetophobic parent is unable to be supportive of a vomiting child, and thus helps the child become emetophobic as well. On the other hand, most emetophobics will tell you that their brothers and sisters and parents and children are not emetophobic.

Q. My son/daughter doesn’t seem to be afraid of vomiting, but he/she is petrified that someone at school is going to vomit. Is this emetophobia?

A. Being afraid of others vomiting is not strictly speaking emetophobia, but the situation you describe begs a lot of questions. A child who expresses fear of others vomiting obviously has a fear of doing it personally. No doubt he or she manifests emetophobia in this way because it takes the focus off him or her and puts it onto others. It would be a good idea to debrief the child in order to see if he or she has emetophobia.

Q. How do I diagnose my child with emetophobia?

A. You’ve read this far, haven’t you? Maybe that’s a sign.

Here are some things that have been observed as characteristic of early emetophobia, in relative order of significance:

  1. An obsession with stomach feelings – By the time a child is old enough to be at risk for emetophobia (age 6 to 10), the parent should have an idea how often the child complains of stomach upsets. If there is a sudden marked increase, try to remember if the child vomited recently. This is apt to be the most critical sign in a child.

Avoid offering antacids to the child. These are only good for acid indigestion, something rather rare in children. Using them as placebos only rewards the child’s inability to distinguish “safe” stomach feelings (those unlikely to lead to vomiting) from true nausea.

  1. An obsession with vomiting as a topic of conversation – Typically a child of that age will be more comfortable discussing their limited vomiting experience with other children than with adults. Although parents probably won’t overhear every playground conversation, they might find a way to casually bring up the subject and see if the child seems interested.

It may also be helpful to use other words to describe vomit and vomiting from what the child is used to hearing. (Luckily, there are lots of other words available! ) The child has perhaps attached a bad connotation to whatever term they’re used to using. Switching to something different can escape the bad connotation and disempower the older term. (More on language later.)

  1. Overreaction to other people’s talk of vomiting – It’s common for adults to use expressions like “It makes me want to puke.” Of course, those past puberty realize this is only a metaphor. If a child becomes agitated at hearing such talk, they likely have emetophobia to some degree. (Note that it is very easy to experiment with the child on this point!)
  2. A narrowing of food choices – While being an idiosyncratic eater is the most common feature of emetophobia in older adolescents and adults, children rarely generalize from their emetophobia to food preferences right away.

Please remember that it is 100% normal for a child to avoid a food he or she has vomited. Many people who are not emetophobics practice this the rest of their lives.

The existence of emetophobia is hinted at when the dietary restrictions pertain to not only this “infamous” food but spread to other foods for which there is no apparent reason for the child to discontinue eating them.

At the same time, remember that pickiness about food is a common trait in children (and adults!) and that a child who is a picky eater but does not display the symptoms listed above in this list is probably not emetophobic.

Q. I’ve read your list and I’m pretty sure my child is an emetophobe. What do I do now?

A. The first thing is to make a point of not confronting him or her about their emetophobia. Remember, their emetophobia stems in large part from an unexpected attack of vomiting which was a blow in one way or another to their sense of self. Pointing this out to them is apt to lead to denial and make their problem and yours more difficult to solve.

One very helpful and subtle thing to do is to slip into conversation that you don’t like to vomit either. You can then discuss commonsense things that everyone can do to avoid vomiting. (See the Vomiting FAQ for lots of tips on avoiding vomiting.) But be careful you don’t give them a new obsession about handwashing, food safety, etc. Your goal is to instill their trust in you as a person who is on their side to keep them from vomiting.

It’s helpful to point out that even though viruses that cause vomiting are going around all the time, people don’t get them very often. (Adult emetophobes reading this: You remember that too!)

Q. Couldn’t it be that they just need to vomit more often? What if I arranged for that to happen?

A. No! No! No! Nothing could be more destructive to the relationship between an emetophobic and their loved one than that. Some (not most) adult emetophobes say they developed emetophobia because their parents made them vomit at one time or another. There are even adult emetophobes who wound up worse than before when someone tried to “cure” them by infecting them or otherwise making them vomit.

When — or if — the child gets into the situation where he or she really does need to vomit, it’s a good idea for you not to push them to do it. You might suggest that vomiting would only take a minute, whereas their nausea will last/has already lasted for hours, but if the child doesn’t respond to that, it will do no good to say more. Pushing them at that point might compound their emetophobia and their frustration with you when it’s over.

Look at the bright side — your child is learning lessons about determination, tenacity, persistence, body mechanics, etc., that might come in handy later!

When the child is back to normal after such an incident, perhaps a discussion about how he or she handled it would be productive. If the child ended up vomiting anyway, you could point out the length of time they unnecessarily prolonged their misery and ask if they would have felt better had they vomited sooner.

Parents and others should refrain from using the phrase “get it over with.” To an emetophobic, vomiting is not something on a level with math homework, taking out garbage, or even getting a tooth drilled. For emetophobics, to vomit is to let themselves fail at something they’ve made a daily effort to prevent for a period of years and to corrupt their mouths (and possibly other parts) with a substance which even the least anxious person regards as foul and disgusting. Remember, let them know that you avoid vomiting too, not that you enjoy getting it over with.

Q. I can’t stand that practically every movie made these days has a vomiting scene. Is there any way to know when one of those is coming?

A. You’re in luck! The web site ScreenIt! does a thorough job of cataloguing what’s in nearly every theatrical release. Go to their site and pull up any movie, and then read the section “Blood/Gore.” If there’s any vomiting in the movie, it will be listed in that section. For example, here’s an excerpt from the page for Riding in Cars with Boys, starring Drew Barrymore:

We see Ray vomit on a bed while having heroin withdrawal problems.

The page for a movie is usually up the weekend it opens. One warning though: Reading the entire page for a movie will pretty much spoil the plot. So be careful to only read the Blood/Gore section.

Q. Does any good come from emetophobia?

A. Emetophobics are probably healthier, on average, due to the great diligence they put into preventing vomiting. Many emetophobics are quite careful when it comes to using alcohol and stand very little chance of ever becoming alcoholic.

Q. I notice you keep saying “vomit.” Don’t you know that there are a lot of synonyms?

A. Yes, we know them. We use the clinical “vomit” here because it is the least judgmental and because being able to say the word can be empowering to an emetophobic. Many people have unpleasant associations with some of the popular euphemisms, although most emetophobics use those words themselves. (Our favorite is the airlines’ euphemism for in-flight vomiting, “motion discomfort.”) And “throwing up” sounds like something children do, much as they would have an “owie.”

We have always taken the position that abbreviating the words on the Internet constitutes paying homage to the fear contained in the concepts those words represent; therefore, no abbreviations are used in this FAQ or on this website.

Q. So what can emetophobics do for help?

A. One can always consult a professional, particularly one specializing in phobias. This is an especially good idea if the phobia is accompanied by depression, severe anxiety or other debilitating disorders. Some people have found medication to be helpful and it has enabled them to live a more ‘normal’ life, whereas others find they don’t need it.

While not a substitute for professional help, there are occasional online chat discussions on the subject. There are also several electronic mail discussion groups. To learn more about these groups or to subscribe, see the main page.

Some phobics are reluctant to talk about vomiting because they are superstitious that if they talk about it, it will happen. (Many sufferers can attest otherwise.) They need to realize that talking about vomiting can greatly reduce their anxiety about it. It also helps them to know that they’re not alone.

I highly recommend that emetophobics not only read this FAQ, that they re-read it, indeed study it. (It’s also helpful to share a copy with any professional who is trying to help.) Phobics who are ready to try some do-it-yourself desensitization might read my Vomiting FAQ in its illustrated version. (Those not ready for desensitization should read the unillustrated version in the meantime.)

Q. What is the DSM-IV code for emetophobia?

A. It would fall under the heading of specific phobia, 300.29.

“Nothing is to be feared. It is only to be understood.”

–Mme. Marie Curie