Developing a Treatment Plan

If you have a child with emetophobia I can direct you to two ready-made options. (Disclaimer: I will receive some revenue for both of these resources.) If you want to teach your child about how to deal with anxiety in general and then add a specific plan for emetophobia, I would recommend the Turnaround program with the emetophobia supplement. If you feel pretty certain that your child is okay in general and the problem is only emetophobia, I have written an interactive book. At the present time it will only work on Apple devices. 

If you are an adult and want a self-help process I recommend you visit Anna Christies site. She has created an interactive website with an excellent hierarchy of gradual steps to help you face the fear as well as instructions about the process. 

Just as a quick refresher, if you haven't read the page describing exposure and response prevention here is a quick explanation. Exposure is facing a fear by moving toward it. Taking an offensive rather than defensive response to it. This is typically done gradually, starting with less challenging tasks and once that is tolerated, moving up to a bit more challenging and so forth. This can be done four different ways and usually in this order.

• First, is exposure by imagination. Rather than being in a situation or around a trigger, you imagine what the fear presents as a threat. This can be broken into steps as well.

• Second, exposure virtually. This can be pictures or videos of what is feared. Again, that can be broken into steps. Generally cartoons, still images, animation and realistic video is the order that would take.

• Third, exposure in the actual setting or with the actual trigger. This can be going to places like a restaurant or wearing clothing that is thought to be contaminated.

• Fourth exposures can be creating physical sensations called interoceptive exposures. Most people with the phobia are scared to get hot (usually in a specific fashion) so the exposure might be to sit in a hot car. Or if getting dizzy is scary, spinning around in a desk chair. 

The other aspect is called response or ritual prevention. It means to stop doing (or thinking) the things that you hope are making you safer. This is also done gradually. Typically, I will start the exposures first and then suggest the gradual reduction of these things. They are often called safety behaviors and I like that because it describes what they are trying to accomplish. One of the first of these I try to address is how people "brace" their bodies when they get anxious. They might tense their jaw for example. Or they may resist or fight a feeling in their throat or stomach and I suggest they just give the feeling permission to be present while we are doing the exposure. 

Usually this whole process is done using something called a hierarchy. As I mentioned, most people start with less challenging (it is all challenging by the way) and gradually go to more difficult tasks step by step. It is quite important that the steps match the phobia. By way of illustration imagine if I decide to run a 5K race. (This is different from a phobia in many ways but will still work to illustrate the process. And for the record, the thought of running a 5K would freak me out.) So first, I would need to think about it and make a decision. I might read about these races and decide which race I would like to enter. I could talk to others about it. Then I might figure out the best shoes and buy them. I might start with an easy jog around the block. Gradually, I would run for longer distances and possibly pick up the pace. There is no way I could just go outside right now and run that far. I would have to gradually develop the tolerance, stamina and strength to do it. I would have to be willing to feel pain in order to build that stamina. If I stop before it hurts I won't improve my distance. That is similar to exposure. You have to feel the anxiety to develop the tolerance and disconfirm the threat. 

The typical hierarchy I use for emetophobia is as follows: (I am indebted to Anna Christie for many of these elements)

Imagination

• Words - I have various synonyms for the feelings and actions associated with emesis. I have them ranked in order as well but they can vary quite a bit from person to person

• Sentences - This adds a bit of context to the words. I have a standard set but I can customize them depending on someone's story. I use the same words from the first step. (By the way, I don't think surprises are a good approach at eh beginning of the process so I am very clear about what we will be doing.)

• Short stories/vignettes - I have a few of these that are common to most people but I often will add in a custom story if relevant to someone's fear. My common settings are school/work, restaurant and home. In these stories, someone else gets sick. The fourth story is first person describing in detail what could happen if someone got sick. I might add a custom story if, for example, a car ride is associated with the phobia. 

Check to see if any safety behaviors can be stopped, postponed or done less then perfectly. Do this as you go through the steps. 

Virtual

• Cartoons - These start with simple drawings where the character looks sick and gradually become more realistic and display the actual act of v**m*ting. 

• Photos - The first set of photos are of people who look like they are n**seated or about to get sick.

• Photos 2 - These are photos of v**m*t. I am probably one of the few people in the world who gets excited if I come upon this and can take a picture of it. There are a zillion photos online but I can't use them in a book or article because they are copyrighted so I like to have my own. Weird right?

• Photos 3 - These are photos of people in the act of v**m*ting. This is, of course, really hard to get a photo of in the moment but there are plenty of them online. College kids seem to have an amazing ability to have their phones ready just at the right moment. 

• Sounds - I have only done this once so far but I am considering adding it in at this point. The following step includes sound so I haven't had a separate category but recently the sound with animation was too challenging for someone and she suggested this step to me. I thought that was very insightful, especially since she is 8. If she reads this, she will know who she is. Nicely done RA. 

• Animation - This step consists of various animations of the act of getting sick. Like every step I try to assemble them in some graduated order. As I mentioned, this is the first step that includes sound so I recommend people watch it first with the volume turned down and once that is tolerated gradually increase the volume. 

• Video - Again, volume off to start. It seems to work to start with babies and move toward older folks. Some videos are clearly staged and some realistic. By the way, if you can find something to talk about such as if it was staged or not, you can keep the exposure going but draw attention to something less distressing. Just helps to ease people into the exposure. 

Situational

Most of the time, once someone has gone through all these steps there are not typically that many things left. Maybe a visit to a location where someone was previously sick for example. If there are foods that are still avoided gradually introduce those back into the diet. Again, think in increments. Someone might not eat a whole sandwich but they might take a bite. That bite is a success. Kids may be reluctant to be away from parents so an overnight with a friend or going to camp might be part of this step. If someone avoids car rides that could be a step. 

Interoceptive

These exposures are much shorter in duration. For example, I might repeat a word over the course of 10 minutes. These exposures are typically 30--45 seconds. Just long enough to get the effect. If a person is avoiding feeling dizzy then spinning around in a desk chair or outside in the grass for 30 seconds would be a good exposure. If a person avoids feeling full then eating enough to feel full could be a step (that might take longer than 30 seconds obviously). Running up stairs to get hot might be a good exposure. Breathing really fast for 30 - 45 seconds will induce feeling dizzy and lightheaded. If someone is avoiding a feeling then you would want to find a way to create part of the feeling and practice it in this step. 

As I mentioned the steps above are usually the order I go. However, I might mix in a situational or interoceptive exposure along the way if it comes up or seems relevant. Phobias take away part of your life. If there is an opportunity to take it back then I might introduce something sooner.