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Is a specific phobia of vomiting part of the obsessive compulsive and related disorders?
Abstract
Aims: To explore whether the phenomenology and co-morbidity of a specific phobia of vomiting (SPOV) (also known as "emetophobia") might best fit within the group of obsessive compulsive and related disorders. Method: Case review of individuals who were assessed for a SPOV (n=83). Results: Sixty-two per-cent of cases reported being markedly or very severely preoccupied by the fear that they might vomit. A majority of people with a SPOV reported either often or always conducting repetitive behaviors such as compulsive washing; reassurance seeking; self-reassurance, counting or superstitious behaviors to prevent vomiting; checking others for signs of illness or checking sell-by dates. Cases that had more frequent hand washing were associated with higher scores on standardized questionnaires for a SPOV and a later age of onset. The diagnosis of OCD formed the highest degree of comorbidity. Conclusions: The results have implications for future research into the nosology and treatment of a SPOV. Clinicians should assess for repetitive behaviors in a SPOV and include them in a formulation and treatment plan. Future research should conduct prospective studies to determine which aspects of the phenomenology of a SPOV might best fit under OC and related disorders.
... Six papers reported data on safety seeking behaviours in SPOV samples (Lipsitz et al., 2001;Price et al., 2012;van Hout & Bouman, 2012;Veale et al., 2012;Veale, Hennig, & Gledhill, 2015;Veale & Lambrou, 2006) (Tables 2 and 4). In an attempt to reduce the likelihood of vomiting, 64.9% (n = 296) checked expiry dates on food; 42.1% (n = 183) washed their hands excessively; 16% (n = 100) checked the state of their own health; 80.8% (n = 83) checked the state of other peoples' health. ...
... Four studies explored comorbidity between SPOV and other Axis I disorders (Sykes, Boschen, & Conlon, 2015) and specifically Eating Disorders (Norris et al., 2014;Veale et al., 2012), OCD (Veale et al., 2015) and Health Anxiety (Veale et al., 2015) (Table 4). Co-morbidity rates for Axis 1 disorders found across all samples of SPOV are presented in Table 5. ...
... Four studies explored comorbidity between SPOV and other Axis I disorders (Sykes, Boschen, & Conlon, 2015) and specifically Eating Disorders (Norris et al., 2014;Veale et al., 2012), OCD (Veale et al., 2015) and Health Anxiety (Veale et al., 2015) (Table 4). Co-morbidity rates for Axis 1 disorders found across all samples of SPOV are presented in Table 5. ...
Specific Phobia of Vomiting (SPOV) is an under-researched disorder compared to other Specific Phobias. A systematic review was conducted to synthesise existing research across areas of phenomenology, aetiology, epidemiology, co-morbidity, assessment measures and treatment.
Online databases (Psychinfo, Embase, Medline, Pubmed and Cochrane Library) were searched using terms related to SPOV and ‘emetophobia’. A manual search of reference lists of included papers was also conducted. In total, 385 articles were found and 24 were included in the review. The review was registered on the PROSPERO register (CRD42016046378).
The review presents a qualitative synthesis of identified studies exploring the features of SPOV including locus of fear, feared consequences of vomiting, and common safety and avoidance behaviours. It also identified articles describing aetiological factors involved in the development of SPOV, co-morbid disorders and the epidemiology of the disorder. Further studies focused on valid and reliable measures to assess SPOV, and treatments that are effective at reducing symptomatology of SPOV and psychological distress.
There are relatively few published research articles on SPOV, and particularly high quality studies exploring effective treatment options for SPOV. Further research should focus on RCTs for comparing different approaches to reducing symptomatology and distress in people with SPOV.
... Phenomenological similarities with obsessive-compulsive disorder (OCD) (e. g., fear of contamination) were also observed. Recent studies found that the most common comorbid diagnoses were general anxiety disorder (GAD), OCD, and hypochondriasis (Sykes, Boschen & Conlon, 2015;Veale, Hennig & Gledhill, 2015). Veale, Costa, Murphy, and Ellison (2012) emphasize that some individuals with emetophobia are falsely diagnosed as suff ering from anorexia nervosa or hypochondriasis. ...
... They may share with hypochondriac patients the fear of getting sick, though this is restricted to vomiting. A recent study of 83 emetophobic cases found a signifi cant symptomatic overlap with OCD (Veale, Hennig & Gledhill, 2015): Results indicate that they were often preoccupied with the worry of vomiting (62.5 %), repetitively checking sell by dates (82.2 %), frequently washing their hands (73.6 %), and constantly reassuring themselves (52.7 %) or seeking the reassurance of others (51.6 %). However, although pa-tients with emetophobia might share the frequent checking behavior and reassurance-seeking with OCD patients, this again is solely restricted to associations with vomiting. ...
... In our own experience, emetophobic patients are especially diffi cult to motivate to expose themselves to vomit or vomiting and to provoke fear and disgust (see also Lipsitz, Fyer, Paterniti & Klein, 2001). After reviewing the broad and often OCD-like symptomatology of emetophobia, Veale, Hennig, and Gledhill (2015) suggested that this phobia may need a more elaborate psychological intervention than just graded exposure. Moreover, we doubt that exposing patients to vomiting actually attacks the pivotal aspects of emetophobia: While most people feel disgust when watching someone vomit or by vomiting themselves and many people show fear of vomiting, only a small proportion actually suff ers from emetophobia. ...
Objective:
Emetophobia is the specific fear of vomiting that usually commences during childhood and adolescence. Cognitive behavioral therapy aims to expose patients to vomiting. In this paper, a newly developed metacognitive concept and treatment approach to this disorder is illustrated within a small case series.
Method:
Three adolescent girls with emetophobia were treated with metacognitive therapy (MCT). Measures of anxiety, worry, depression, and metacognitions before and after the treatment were documented.
Results:
All patients recovered during the course of 8 to 11 sessions, and measurements of anxiety, worry, depression, and metacognitions dropped markedly.
Conclusions:
MCT presents a valuable treatment option for emetophobia in adolescents.
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... Indeed, emetophobia exhibits a considerable overlap in clinical features with other anxiety disorders [15], which is also illustrated by the high rates of comorbidity and general vulnerability to anxiety [8]. Specifically, individuals with emetophobia frequently present with concurrent diagnoses of generalized anxiety disorder, panic disorder, obsessivecompulsive disorder (OCD), and social anxiety [6,9,[16][17][18]. Consistent with other anxiety disorders, the marked fear of vomiting is met with excessive worry and extensive avoidance. ...
... Indeed, up to 78 % of individuals with emetophobia may pursue consultations with medical professionals due to physical symptoms [e.g., nausea; 5], exemplifying their elevated health-related concerns and negative interpretations of otherwise innocuous symptoms [3,9]. On the other hand, safety behaviors may become more magical in nature and manifest as rituals, paralleling symptoms observed in OCD [18]. Rituals revolving around food consumption are particularly common, which can entail certain food preparation routines, excessive hand washing, and repeated checking of expiration dates [3,6,17]. ...
... Rituals revolving around food consumption are particularly common, which can entail certain food preparation routines, excessive hand washing, and repeated checking of expiration dates [3,6,17]. As such, the phenomenological overlap and the high incidence of compulsive, repetitive behaviors have led some researchers to speculate if emetophobia should be classified under obsessive compulsive and related disorders [18], though further clarification is warranted. ...
Emetophobia is an under-researched disorder characterized by a specific fear of vomiting. There is a paucity of research on this impairing condition, with extant examinations being largely limited to adult samples and online communities. The present study examined the incidence, phenomenology, and correlates of emetophobia in 305 Salvadorian youths. Caregivers completed a battery of questionnaires regarding the youth’s symptoms of emetophobia, internalizing/externalizing symptoms, health anxiety, and obsessive–compulsive symptoms. Approximately 7.5 % of the sample was elevated on emetophobia symptoms, and higher levels of emetophobia symptoms were correlated with higher levels of internalizing, externalizing, health anxiety, and obsessive–compulsive symptoms, and lower levels of adaptive functioning. Youths meeting the cutoff for elevated emetophobia symptoms versus those who did not demonstrated significantly higher levels of externalizing behaviors, as well as general obsessive–compulsive symptoms, especially doubting/checking and neutralizing behaviors. These findings are hoped to help improve the conceptualization and treatment of this poorly understood disorder.
... In OCD, the obsessive fear of vomiting is associated with intrusive thoughts related to emesis and many rituals to prevent this occurrence, such as carrying a container in the event vomiting occurs or checking expiry dates. Other obsessions and compulsions such as fear of contamination and excessive hand washing would be expected in OCD (Veale et al 2015;APA, 2013). The treatment of children with simple emetophobia using graded exposure has been described previously in the literature (Faye, Gawande, Tadke, Kirpekar & Bhave, 2013;Manassis & Kalman, 1990;Moran & O'Brien, 2005;Veale, Hennig & Gledhill, 2015;Whitton, Luiselli & Donaldson, 2006). ...
... Other obsessions and compulsions such as fear of contamination and excessive hand washing would be expected in OCD (Veale et al 2015;APA, 2013). The treatment of children with simple emetophobia using graded exposure has been described previously in the literature (Faye, Gawande, Tadke, Kirpekar & Bhave, 2013;Manassis & Kalman, 1990;Moran & O'Brien, 2005;Veale, Hennig & Gledhill, 2015;Whitton, Luiselli & Donaldson, 2006). Here we report on one child and one adolescent whose primary initial symptom, fear of vomiting, presented diagnostic challenges due to complex medical and psychiatric co-morbidity. ...
Fear of vomiting can be a symptom associated with several disorders, including Eating Disorders (ED), Specific Phobia (Emetophobia), Avoidant Restrictive Food Intake Disorder (ARFID) and Obsessive Compulsive Disorder (OCD), making proper diagnosis challenging. At this time the literature exploring this symptom is limited, and to our knowledge very few cases have been described in the child and adolescent population. We report here the cases of one child and one adolescent presenting with significant weight loss, food restriction and fear of vomiting. The child's fear of vomiting masked a concurrent desire to achieve fitness and weight loss, which was uncovered following weight restoration. The adolescent patient, although significantly underweight and food avoidant, also expressed no concerns with body image, until weight restored. The history, course in hospital and management of these patients is discussed, along with several challenges that complicated the diagnosis.
... Early caregiving may therefore present particular difficulties for parents with SPOV and may start to directly impact on children via modelling or avoidance. In their study, 70.8% of respondents reported asking children to wash hands excessively as a result of their own fears (Veale et al., 2015). This can be an area of concern for parents who are worried about the impact on children who may pick up on and start to copy their behaviour independently (Gerull and Rapee, 2002). ...
Specific phobia of vomiting (SPOV) can be a severe and debilitating anxiety disorder and affects women in the childbearing years. The perinatal period and early parenthood is a time of increased risk for the onset or exacerbation of anxiety problems, which can have an impact on both the woman and the developing child. There are particular issues pertinent to the physical experience of pregnancy and tasks of early caregiving that women with SPOV may find difficult or distressing to confront, but these are not well documented. Cognitive behavioural therapy (CBT) focused on exposure to vomit cues and processing distressing early memories of vomiting is an effective treatment for SPOV. This paper describes the successful CBT treatment of two young mothers with SPOV, outlining the challenges faced by parents at this time and the need to take this into account in treatment, using illustrative case material.
Key learning aims
(1) To understand how specific phobia of vomiting (SPOV) affects women in early parenthood.
(2) To know how to target and update traumatic early memories of vomiting with imagery rescripting.
(3) To know how to design and carry out effective behavioural experiments for perinatal SPOV.
(4) To understand how to take mother, baby, and the mother–infant relationship into account in SPOV treatment.
... In Veale e Lambrou (2006) sono emerse delle somiglianze e differenze psicopatologiche tra i soggetti aventi il disturbo di panico e i soggetti emetofobici, quali ad esempio i comportamenti di prevenzione e di ricerca di sicurezza, attenzione selettiva per le sensazioni corporee interne ed un forte senso di ipervigilanza nel vedere gli altri vomitare; tutti questi processi sembrano mantenere la paura di vomitare in coloro che sono colpiti da questa fobia. Inoltre, anche il DOC pare essere in comorbidità con lo SPOV (Veale et al., 2015), con una stima del 12%. I pazienti riferiscono sintomi quali pensieri ripetitivi e comportamenti di evitamento motivati a prevenire il rischio di vomito (e.g. ...
Emetophobia or SPOV (specific phobia for vomiting) is an anxiety disorder still little explored. In the DSM-5 (APA, 2013) it appears in anxiety disorders within the specific phobias section, in the wording "other". Specific phobia is an irrational and exaggerated fear of a peculiar or specific situation or object, which generates a deep and excessive anxious state. The exposure or anticipation of the phobic stimulus induces a strong anxiety crisis in the subject, which is why and for this reason the phobic subjects try in every way to avoid exposure to the stimulus that generates fear.
Individuals are aware of their fear, they are able to describe it and they are also aware of its irrationality; but they failing to win it, they develop a series of strategies to deal with it.
This work proposes an international systematic review of the literature based on Emetophobic Disorder. Literature studies of the last 18 years (2000-2018) have been considered. From the 23 selected empirical studies, we tried to investigate the different variables interconnected with the emetophobic disorder and what treatment, to date, is the most effective.
The diagnosis of emetophobic disorder is very difficult to determine because the condition presents with symptoms that are also observed in obsessive-compulsive disorder, panic disorder, agoraphobia panic disorder and generalized anxiety disorder (Boschen, 2007 ; Veale, 2009; van Hout & Bouman, 2012).Therefore, the international literature review aims to highlight the importance of identifying the presence of other disorders in the emetophobic individual, not only for a diagnostic classification but also for an effective treatment.
... Notwithstanding, OCD and emetophobia may be symptomatically related. A recent review of adult cases with Specific Phobia of Vomiting (SPOV) noted that cases with more hand washing and other repetitive behaviours were associated with higher scores on specific phobia of vomiting questionnaires with an observed comorbidity with OCD in 12% of the participants (Veale, Hennig, & Gledhill, 2015). These authors emphasized the importance of formulating and targeting OCD symptoms when present in the treatment of adult patients with emetophobia. ...
We present a case of an eight-year-old boy with a specific phobia of vomiting who developed subsequent food restriction and weight loss. Our case report includes a review of treatment modalities for specific phobias including cognitive behavioural and exposure therapy in young children and the importance of parental involvement in the treatment process. After an initial assessment and diagnosis of this boy with emetophobia, treatment took place over ten subsequent visits, one hour each in duration. His treatment included a cognitive approach utilizing exposure therapy to re-introduce foods to his diet, working through a fear hierarchy, addressing cognitive distortions/misconceptions and psychoeducational supports. Intermittent reinforcement was applied to help extinguish what we believe was an associatively learned fear of vomiting. Outcomes of the treatment were measured by changes in behaviour and overall increase in food intake reported by the patient's parents. On completion of treatment, the family was no longer concerned with the amount and variety of food he was eating, the patient reported less nausea, and he was more likely to eat in public. A post-treatment three-week telephone follow-up showed continued gains. Congruent with reported literature
,
this case confirms and highlights the efficacy of exposure therapy and age-appropriate cognitive treatment adaptations in treatment of emetophobia. In addition, parental education and participation is recommended in treatment of child cases.
Emetophobia (specific phobia of vomiting) emerges as one of the most neglected clinical conditions in clinical practice and academic literature. In this article, a phenomenological, epidemiologic and clinical picture of emetophobia is presented and the cognitive behavioral model is discussed as a therapeutic approach for its treatment [JCBPR 2017; 6(1.000): 39-48]
Method:
24 participants (23 women and 1 man) were randomly allocated to either 12 sessions of CBT or a wait list.
Results:
At the end of the treatment, CBT was significantly more efficacious than the wait list with a large effect size (Cohen's d=1.53) on the Specific Phobia of Vomiting Inventory between the two groups after 12 sessions. Six (50%) of the participants receiving CBT achieved clinically significant change compared to 2 (16%) participants in the wait list group. Eight (58.3%) participants receiving CBT achieved reliable improvement compared to 2 (16%) participants in the wait list group.
Conclusions:
A SPOV is a condition treatable by CBT but further developments are required to increase efficacy.
The World Health Organization is in the process of preparing the eleventh revision of the International Classification of Diseases (ICD-11), scheduled for presentation to the World Health Assembly for approval in 2017. The International Advisory Group for the Revision of the ICD-10 Mental and Behavioural Disorders made improvement in clinical utility an organizing priority for the revision. The uneven nature of the diagnostic information included in the ICD-10 Clinical Descriptions and Diagnostic Guidelines (CDDG), especially with respect to differential diagnosis, is a major shortcoming in terms of its usefulness to clinicians. Consequently, ICD-11 Working Groups were asked to collate diagnostic information about the disorders under their purview using a standardized template (referred to as a "Content Form"). Using the information provided in the Content Forms as source material, the ICD-11 CDDG are being developed with a uniform structure. The effectiveness of this format in producing more consistent clinical judgments in ICD-11 as compared to ICD-10 is currently being tested in a series of Internet-based field studies using standardized case material, and will also be tested in clinical settings.
© 2015 World Psychiatric Association.
DSM-IV categorized obsessive-compulsive disorder (OCD) as an anxiety disorder, body dysmorphic disorder (BDD) as a somatoform disorder, and trichotillomania as an impulse control disorder not elsewhere classified. In DSM-5, these three disorders, together with hoarding disorder and excoriation (skin picking) disorder, which are new disorders in DSM-5, are classified together in a new chapter of obsessive-compulsive and related disorders. In this paper we consider some of the relevant considerations at play in making this change, some of the potential advantages and disadvantages of this new chapter, and a number of potential research and clinical misconceptions about the new chapter.
The World Health Organization (WHO) is currently revisiting the ICD. In the 10th version of the ICD, approved in 1990, hypochondriacal symptoms are described in the context of both the primary condition hypochondriacal disorder and as secondary symptoms within a range of other mental disorders. Expansion of the research base since 1990 makes a critical evaluation and revision of both the definition and classification of hypochondriacal disorder timely. This article addresses the considerations reviewed by members of the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders in their proposal for the description and classification of hypochondriasis. The proposed revision emphasizes the phenomenological overlap with both anxiety disorders (e.g., fear, hypervigilance to bodily symptoms, and avoidance) and obsessive-compulsive and related disorders (e.g., preoccupation and repetitive behaviors) and the distinction from the somatoform disorders (presence of somatic symptom is not a critical characteristic). This revision aims to improve clinical utility by enabling better recognition and treatment of patients with hypochondriasis within the broad range of global health care settings.
Assessment options are extremely limited for the evaluation of treatment outcome in a specific phobia of vomiting (emetophobia). We aimed to assist researchers and clinicians in the measurement of cognitive processes and behaviors that are characteristic of the disorder for treatment planning and outcome measurement. We developed the specific phobia of vomiting inventory (SPOVI). A series of measures, including the SPOVI, were given to two groups: a group diagnosed with a specific phobia of vomiting and a community control group. Item characteristics, reliability, and factor structure were analysed. Convergent validity with measures of related constructs was determined. The SPOVI was found to have good reliability and validity in the measurement of a phobia of vomiting. The scale has a two-factor structure, with one factor characterised by avoidance symptoms and a second factor comprised of threat monitoring. It is sensitive to change during treatment. The results provide initial evidence of the psychometric qualities of the SPOVI and its suitability for use in clinical practice and research.
A survey of individuals was conducted on self-diagnosed vomit phobics compared to panic disorder and non-clinical controls. Vomit phobics were overwhelmingly female and had had symptoms for over 25 years. They were significantly more likely to fear themselves vomiting (in public and private situations) than fear others vomiting. The vomit phobics interpreted sensations of nausea as impending vomit and had a wide range of safety seeking and avoidance behaviours that were maintaining their fear. Although the vomit phobics reported feeling nauseous more often, there was no difference in their frequency of vomiting compared to the control group. The clinical implications of the study for therapy are discussed.
This article summarizes the current knowledge and treatment for a specific phobia of vomiting (SPOV). It is relatively uncommon compared to other specific phobias but may have been misdiagnosed in catchment-area surveys. The differential diagnosis of SPOV includes obsessive–compulsive disorder, hypochondriacal disorder and anorexia nervosa. I discuss the following: a model that is linked to past aversive experiences of vomiting; conducting a clinical assessment; making a formulation; psycho-education, engagement and therapy. The strategies employed depend on the formulation but are likely to include: exposure in vivo to cues of vomiting, exposure in imagination and role-plays of vomiting, imagery re-scripting, behavioural experiments; and dropping of safety-seeking behaviours.
A self-rated measure of health anxiety should be sensitive across the full range of intensity (from mild concern to frank hypochondriasis) and should differentiate people suffering from health anxiety from those who have actual physical illness but who are not excessively concerned about their health. It should also encompass the full range of clinical symptoms characteristic of clinical hypochondriasis. The development and validation of such a scale is described.
Three studies were conducted. First, the questionnaire was validated by comparing the responses of patients suffering from hypochondriasis with those suffering from hypochondriasis and panic disorder, panic disorder, social phobia and non-patient controls. Secondly, a state version of the questionnaire was administered to patients undergoing cognitive-behavioural treatment or wait-list in order to examine the measure's sensitivity to change. In the third study, a shortened version was developed and validated in similar types of sample, and in a range of samples of people seeking medical help for physical illness.
The scale was found to be reliable and to have a high internal consistency. Hypochondriacal patients scored significantly higher than anxiety disorder patients, including both social phobic patients and panic disorder patients as well as normal controls. In the second study, a 'state' version of the scale was found to be sensitive to treatment effects, and to correlate very highly with a clinician rating based on an interview of present clinical state. A development and refinement of the scale (intended to reflect more fully the range of symptoms of and reactions to hypochondriasis) was found to be reliable and valid. A very short (14 item) version of the scale was found to have comparable properties to the full length scale.
The HAI is a reliable and valid measure of health anxiety. It is likely to be useful as a brief screening instrument, as there is a short form which correlates highly with the longer version.
Data from 33 randomized treatment studies were subjected to a meta-analysis to address questions surrounding the efficacy of psychological approaches in the treatment of specific phobia. As expected, exposure-based treatment produced large effects sizes relative to no treatment. They also outperformed placebo conditions and alternative active psychotherapeutic approaches. Treatments involving in vivo contact with the phobic target also outperformed alternative modes of exposure (e.g., imaginal exposure, virtual reality, etc.) at post-treatment but not at follow-up. Placebo treatments were significantly more effective than no treatment suggesting that specific phobia sufferers are moderately responsive to placebo interventions. Multi-session treatments marginally outperformed single-session treatments on domain-specific questionnaire measures of phobic dysfunction, and moderator analyses revealed that more sessions predicted more favorable outcomes. Contrary to expectation, effect sizes for the major comparisons of interest were not moderated by type of specific phobia. These findings provide the first quantitative summary evidence supporting the superiority of exposure-based treatments over alternative treatment approaches for those presenting with specific phobia. Recommendations for future research are also discussed.
Emetophobia (fear of vomiting) is an anxiety disorder in which individuals report clinical levels of fear that they may vomit or be exposed to the vomit of others. The prevalence of comorbidity of emetophobia with other conditions has previously only been investigated using self-report instruments.
Sixty-four adults with emetophobia participated in an online structured clinical diagnostic interview assessing the presence of emetophobia and other conditions.
Higher comorbidity for depression, generalized anxiety disorder, panic disorder, social anxiety disorder and obsessive-compulsive disorder were found in participants compared with general population norms.
Emetophobia is commonly comorbid with other anxiety and depressive disorders. Comorbidity rates, when assessed using a structured clinical interview, were lower than previously reported using self-report alone. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner Message Emetophobia (specific phobia of vomiting) is a clinical fear of vomiting. Individuals with emetophobia show high comorbidity with other anxiety and mood disorders. The most common comorbid conditions were generalized anxiety disorder, panic disorder, hypochondriasis and obsessive-compulsive disorder. Clinicians should ensure that they assess for the presence of comorbid conditions when treating emetophobia.
Copyright © 2015 John Wiley & Sons, Ltd.
Through electronic mail, we surveyed members of an internet support group for emetophobia (fear of vomiting). Respondents were 50 women and 6 men with a mean age of 31 years. Results suggest that, for this sample, emetophobia is a disorder of early onset and chronic course, with highly persistent and intrusive symptoms. Emetophobia is implicated in social, home-marital, and occupational impairment and it causes significant constriction of leisure activities. Nearly half of women avoided or delayed becoming pregnant. About three quarters of respondents have eating rituals or significantly limit the foods they eat. Respondents describe other problems such as depression, panic attacks, social anxiety, compulsions, and frequent history of childhood separation anxiety. Depression and Anxiety 14:149–152, 2001. © 2001 Wiley-Liss, Inc.
Behavioral interventions encompassing imaginal flooding, response prevention, graduated exposure and relaxation were used to treat two patients with persistent, disabling bowel obsessions. The cases illustrate the successful treatment of this condition and provides data bearing on the phenomenology of the syndrome including its relationship to panic and obsessional disorders.
The aim of this study was to explore the eating behaviour in people with a specific phobia of vomiting (SPOV), and whether those identified as restricting their food had a greater degree of psychopathology and impairment than those who do not restrict their food.
We recruited 94 participants with SPOV. They were divided into those who reported restricting their food (SPOV-R) (n = 32) because of fear of vomiting and those who did not restrict their food (SPOV-NR) (n = 62).
People with SPOV frequently have abnormal eating behaviours to reduce the perceived risk of vomiting. Only 3.7% had a body mass index (BMI) of less than 17.5, and 8.5% had a BMI of less than 18.5. The SPOV-R group had significantly higher frequency of psychopathology and abnormal eating behaviours than the SPOV-NR group.
Abnormal eating behaviour, BMI, and the degree of food restriction are important factors in the assessment of SPOV.
AND OBJECTIVES: Specific phobia of vomiting (SPOV) is a chronic, pervasive and debilitating disorder which is clinically regarded as difficult to treat. Research into its development, maintenance and treatment has been limited. This study explored the prevalence and characteristics of intrusive mental imagery in people with SPOV. It investigated the relationship between presence of imagery and severity of phobia.
Thirty-six participants meeting DSM-IV criteria for SPOV were recruited from online support groups and outpatient clinics. A semi-structured quantitative interview was administered.
Twenty-nine (81%) participants reported multi-sensory intrusive imagery of adult (52%) and childhood memories (31%) and worst case scenarios ("flashforwards") of vomiting (17%). Extent of imagery was significantly related to severity of phobia. Participants primarily fearing others vomiting had less severe phobic symptoms.
No control group was used and a heterogeneous sample of clinical and community participants was recruited. Correlational data comparing extent of imagery with severity of SPOV symptoms were derived from as yet unvalidated measures.
Intrusive mental imagery is a clinically important feature of SPOV and may contribute to its maintenance. Causality needs to be demonstrated.
Unlabelled:
Specific phobia of vomiting (also known as emetophobia) is a relatively understudied phobia with respect to its aetiology, clinical features and treatment. In this stage, research is mostly based on people with self-reported fear of vomiting. This paper presents a survey on the clinical features of fear of vomiting of individuals. Self-reported vomit-fearful subjects from the Dutch community and from an Internet support group are included. Both vomit-fearful groups were characterized by high reports of fear, the presence of panic symptoms, and by extensive avoidance and safety behaviours. They also reported other psychiatric complaints, which were measured with a structured screening instrument. Vomiting complaints started mostly in late puberty. A significant proportion of the vomit-fearful participants had a treatment history. The prevalence rate of fear of vomiting in the community sample was established at 8.8% (female : male ratio = 4:1). Overall, results show that fear of vomiting is a common phenomenon, which can seriously impair daily functioning. Finally, clinical questions to be addressed in future research are formulated.
Key practitioner message:
Specific phobia of vomiting (also known as emetophobia) is among the least studied phobias. Most clinical data come from research with self-described fear of vomiting. This paper presents data on the clinical features, prevalence and additional psychiatric complaints of fear of vomiting in two vomit-fearful samples and one control sample with no fear of vomiting. Estimates of prevalence of fear of vomiting in a Dutch community sample were established at 1.8% for men and 7% for women. Evidence suggests that fear of vomiting is a chronic and disabling condition that may cause significant impairment in daily functioning.
Four adolescent girls were referred for psychiatric assessment because of suspected anorexia nervosa. Although all of them had lost at least 15% of their body weight, investigation showed that they did not meet the criteria for anorexia nervosa. In all cases, refusal to eat resulted from fear of vomiting following a viral illness and not from a desire to lose weight. Their family configurations and personal histories showed many similarities, including constricted range of affect and a notable lack of anger. With counseling and, in one case, psychotropic medication, the patients recovered promptly.
The Yale-Brown Obsessive Compulsive Scale was designed to remedy the problems of existing rating scales by providing a specific measure of the severity of symptoms of obsessive-compulsive disorder that is not influenced by the type of obsessions or compulsions present. The scale is a clinician-rated, 10-item scale, each item rated from 0 (no symptoms) to 4 (extreme symptoms) (total range, 0 to 40), with separate subtotals for severity of obsessions and compulsions. In a study involving four raters and 40 patients with obsessive-compulsive disorder at various stages of treatment, interrater reliability for the total Yale-Brown Scale score and each of the 10 individual items was excellent, with a high degree of internal consistency among all item scores demonstrated with Cronbach's alpha coefficient. Based on pretreatment assessment of 42 patients with obsessive-compulsive disorder, each item was frequently endorsed and measured across a range of severity. These findings suggest that the Yale-Brown Scale is a reliable instrument for measuring the severity of illness in patients with obsessive-compulsive disorder with a range of severity and types of obsessive-compulsive symptoms.
The authors report on four patients with disabling bowel obsessions who responded to tricyclic antidepressant medication despite the absence of depressive symptoms. The relationship of this symptom constellation to DSM-III obsessive-compulsive disorder and social phobia is discussed.
Bowel obsessions have long been recognized in clinical settings, usually presenting as an overwhelming fear of losing bowel control in public. Conceptual issues with regard to this disorder have hampered treatment efforts. For example, disagreement exists as to its proper classification within the spectrum of anxiety disorders: it has been conceptualized both as a variant of obsessive-compulsive disorder and as a symptom of social phobia, panic disorder, and agoraphobia. In addition, the comorbidity of bowel obsessions and functional bowel disorders such as irritable bowel syndrome is not understood. While reports of pharmacological intervention exist, little has been written about psychological treatment techniques. This paper uses two cases studies of successful behavioral treatment of bowel obsessions as illustrations to address the above issues.
Fear of vomiting (emetophobia) is a poorly understood anxiety disorder, with little research published into its conceptualization or treatment. The current article uses established cognitive and behavioral models of other anxiety disorders as a basis from which to propose a detailed model of emetophobia. The model proposes that emetophobia results from a constellation of factors including a general anxiety-vulnerability factor, a tendency to somatize anxiety as gastrointestinal distress, a tendency to catastrophically misappraise nausea and other gastrointestinal symptoms, hypervigilance to gastrointestinal cues, beliefs about the unacceptability of vomiting, negatively reinforced avoidance behavior, and selective confirmation biases. A formulation-based treatment package for emetophobia is outlined, including arousal management skills, distraction/attention training, exposure and cognitive restructuring.
This study determined the prevalence, age of onset, comorbidity, and impairment associated with specific phobia subtypes in the community. Data were drawn from the Dresden Mental Health Study (N=2064), a representative community-based sample of young women in Dresden, Germany. The lifetime prevalence of any specific phobia was 12.8%, with subtypes ranging in prevalence between 0.2% (vomiting, infections) and 5.0% (animals). There were significant differences in the mean age of onset of specific phobias. Significant differences in comorbidity patterns also emerged between subtypes. No significant differences were found in level of impairment associated with the subtypes. The findings suggest that specific phobias are common among young women and that they differ in prevalence, associated comorbidity, and mean age of onset. These data suggest significant differences in the phenomenology and clinical significance of specific phobia subtypes.
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