Welcome to our first Case Conference at Worrywise. We open with what might surprise some as one of the most common phobias we see in our practice—the fear of throwing up. Some children develop a fear because of unpleasant memories of being caught off guard, throwing up on themselves, or being taken by surprise seeing a classmate get sick. Sometimes adults reactions to a child's getting sick—whisking them down the hallway, concerned about the furniture or rugs—amplify a child's feeling that something very wrong is happening. An additional challenge with vomit phobias is that just thinking about them can make kids feel queasy. This only reinforces their fear that throwing up is imminent. Making the distinction between feeling queasy because you're worrying, and feeling queasy because you are about to get sick is important to do early on.
As you will see, my colleague at the Children's Center, Dr. Larina Kase, helps her patient—who has obsessive compulsive disorder as well—get to the point where she can live with the uncertainty about getting sick, and not have it run her life. As with all anxieties, the goal is not to get a guarantee of safety, rather it is to accurately estimate the risks as well as your ability to manage them. We welcome your feedback, please email us with questions, or if you are a therapist interested in participating in this forum, let us know.
Tamar Chansky, Ph.D.
Director, Children's Center for OCD and Anxiety
Case Conference: Case of Sarah—Fear of Vomiting
Larina Kase, Psy.D., M.B.A.
Children's Center for OCD and Anxiety
Overview: The Fear of Vomiting
Many people of all ages fear vomiting. And many other people, most people in fact, find vomiting very unpleasant and disgusting. You probably feel this way too. Because of the "disgust factor" and the fact that vomiting typically entails feeling horrible and nauseated, vomit phobias can be difficult to treat. Exposure-based forms of cognitive-behavioral therapies are, however, quite effective in helping patients overcome their fears of throwing up.
Introduction to Sara and the Diagnosis Process
To illustrate the nature of the treatment, I'm going to walk you through a case example of how I treated a 12-year-old girl who was extremely fearful of vomiting, so much that she was avoiding school in the winter.
I'd like to clarify the diagnosis of vomit phobia versus OCD. The fear of vomiting can be a vomit phobia, which is a specific phobia, similar to fears of heights, dogs, storms, spiders, and other things. It can also be a part of obsessive-compulsive disorder (OCD). Determining the difference can be tricky, but it is important primarily because the clinician will want to be on the lookout for subtle rituals that are more likely to occur with OCD. With phobias, the primary symptom accompanying fear that you will see is avoidance. A child who is afraid of dogs will avoid dogs. A teenager who is afraid of elevators will take the stairs. With OCD, on the other hand, clients are likely to experience additional ritualistic behaviors, like mental rituals, excessive checking, and superstitious behaviors.
Sara had obsessive-compulsive disorder and at the time of her presentation for treatment her primary symptom was the fear of vomiting. Here is how I knew that Sara had OCD and not simply a vomit phobia:
She engaged in subtle rituals such as trying to have a "healthy thought." If she had a thought about getting sick, she would try to neutralize it with a thought about being healthy and not getting sick.
She showed many subtle rituals, such as not sitting on a seat in class where a student had become sick a year prior.
She engaged in rituals that are hallmark symptoms of OCD such as tapping, repeating, and rubbing.
She used the common ritual of asking people for reassurance, "Are you sure no one has ever been sick here before?" "Are you sure I won't get sick if I eat that?"
She had a history of additional tell-tale OCD fears and habits, including hoarding, perfectionism, superstitious behaviors, and lucky and unlucky numbers.
Exposure treatment requires a good deal of motivation and trust on the part of the patient. Sara had these qualities. Through the use of humor and rapport-building a strong therapeutic alliance was created. Trust is further built when the therapist engages in exposures along with the patient.
Sara was able to trust me even though she believed at times that many of the exposures I recommended were "crazy." I asked that she practice her assigned exposures three times per day and she did for the most part, unless something like a birthday party or holiday came up in which we gave her a break from her practices.
The First Treatment Component: Getting Used to Throw Up
I designed four types of exposures for Sara. The first were created to help her get used to the various sites, sounds, and smells associated with throwing up. We did things like walk around in the subway where it did not smell very good. We walked on a university campus near fraternity and sorority houses because there could be throw-up on the sidewalk. Sara and I looked at photos of throw up and read about vomit on the Internet. We made tapes of gagging sounds.
Towards the top of Sara's hierarchy was an exposure to fake vomit. With her mother's help, we concocted a recipe of fake vomit out of minestrone soup and refried beans. We then went into the bathroom in my office building, put the mixtures in our mouths, and ran into the stall, pretending we were sick, and "barfed" the mixture up into the toilet. We made sure to have some splatters on the toilet seat as Sara distinctly remembered disgusting splattering the last time she was sick.
The Second Treatment Component: Taking "Risks"
The second type of exposures were those designed to increase her willingness to take risks around sick people. Before treatment Sara would not walk by the nurse's office or breathe near people who had been sick. As part of her exposures, she began walking near the nurse's office at school and eventually went in there and hung around near sick students. If someone was sick over the weekend, at school on Monday she no longer avoided them as she once would, and instead carried on a normal conversation with them. She also sat in parts of her house that she had been avoiding because she had once been sick there, and ate the foods that she associated with being sick.
The Third Treatment Component: Those Miserable Physical Feelings
The third type of exposures that Sara and I did were those designed to create the physical sensations associated with vomiting. Sara, like many children and adults with vomit phobia, feared the horrible nausea, gagging, and associated symptoms of getting sick. We used interoceptive exercises (aimed to induce physical sensations) similar to those used in the treatment of panic disorder to help Sara habituated to uncomfortable sensations and learned that they tend to go away quickly. Some of the exercises we did included:
Spinning around in a chair
Eating a big meal and drinking a lot of soda or water and then walking up and down stairs
Working with a nurse to do a swab of the patient's throat similar to a strep culture
Clenching stomach muscles abruptly as if just being punched in the chest
Riding on roller coasters and other nauseating amusement park rides (this also worked as an exposure to increasing the risk of being sick)
The Fourth Treatment Component: Imaginal Exposure
The fourth type of exposure is called "imaginal exposure." Some therapists actually have patients with vomit phobia induce vomiting to learn that their feared consequence is unlikely to come true. When clients face their worst fear and learn that they can handle it, their anxiety typically reduces dramatically. And sometimes when clients don't confront the top of their fear ladder of fear hierarchy, they remain fearful. The fact that doing actual exposures to vomiting in real life can be so helpful can create a dilemma for therapists. I tend to not do in vivo vomiting exposures. While I help clients face their worst fears in general, I do not tend to do so with my vomit phobia patients, particularly with children and teenagers. The primary reason for not doing actual exposures to getting sick is that do not feel comfortable helping teenage girls, many of whom have perfectionism, body image issues, and other risk factors for eating disorders, to make themselves vomit. Therefore I did not want to do exposure to actually getting sick with a 12 year old girl. Instead we did exposures in imagination, also known as "imaginal exposure." Clients, when picturing their worst fear, learn that it is unlikely to come true and that even if it did they would be able to manage it.
I asked Sara to think about her worst possible fear. She was afraid she would vomit in class and make a fool of herself. In the imaginal exposure we had her picture herself vomiting all over her classmates for an entire class period. The nurse was so grossed out by Sara that she wouldn't let her into the nurse's office. Sara had to sit outside while she waited to be picked up and when her mother came she wouldn't allow her in the car. She had to ride in the station-wagon part in the back with the dog. When she returned to school the next week, everyone made fun of her saying, "Eeeww! Sara is the most disgusting girl ever. Don't let her get near you or she'll barf all over you!" No one talked to her for an entire year and she lost all her friends.
After repeating this imaginal exposure several times, Sara found the ideas to be funny, even though they were initially anxiety-provoking. After twelve repetitions her anxiety was down to a rating of zero.
The Fifth Treatment Component: Changing Thoughts
I did not do direct cognitive restructuring with Sara as the treatment was primarily behavioral in nature. Because of her reassurance-seeking ritual, I limited the amount of discussion that we did in session and focused more on exposures. I did, however, focus on assessing the outcomes of the exposures and to help Sara see that her feared consequence did not come true. We also discussed the importance of accepting a greater level of risk in life, and how not doing so would keep her from fun activities like amusement parks and sleepovers.
An important point to mention is that our goal was not to help Sara to like throwing up or to not find it to be disgusting. I believe that she will always find it disgusting, although slightly less so. Instead, the goal was to take away the fear of throwing up, and help Sara to see that even if she did get sick, it would be a time-limited experience and the consequences would not be disastrous. In fact, she would probably feel much better afterwards because her body needed to release the toxin or whatever was making it sick.
"I Might Not Like it, But I'm Not Afraid of It"
At the end of treatment, Sara was able to sit in the nurse's office, be near people who had been sick, and ride on roller coasters. She was thrilled with her progress and told me, "Now I can face anything that I'm afraid of."
I got a call from her mother recently saying that Sara actually had gotten sick and she handled it just fine—and she felt better afterwards.
As I mentioned at the beginning of this case study, vomit phobias can be difficult to treat because of the disgust factor and the fact that the top of the fear hierarchy (actually vomiting) is typically not confronted. I have found that engaging the client's motivation at the beginning of treatment is crucial, and that Sara's motivation was one of the keys to her success. She came in relatively motivated, however, we spent a good amount of time discussing the benefits to overcoming her fears, and recognizing her successes and accomplishments. These techniques helped to build her motivation over time.
In working with other clients with fears of vomiting who were less motivated or trusting, I have found it important to put them in charge of their treatment and feel that they have some control over the process. When I suggest an exposure and the patient balks, I will say, "Okay, what part of that could you try?" and usually we will end up working our way up to the original exposure I suggested. I have also found that modeling exposures a few times has been helpful.
Another strength that Sara possessed was the discipline to get herself to do practice exposure exercises. Had she not shown this, I would have asked her if it would be helpful to ask someone in her life to be her coach outside of sessions or we would create a reward system.
Because Sara's fear was so intense, she serves as an excellent example that clients can overcome their fears, especially when they engage in treatment, focus on the goals and desirable outcome, connect with their therapist (or find a new therapist if rapport is not established), and do many, many (and I mean many) exposures.
Brought to you by The Children's Center for OCD and Anxiety.