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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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© 2016 Hogrefe Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2016), 44, 1–10
DOI 10.1024/1422-4917/a000464
Emetophobia – A Metacognitive
Therapeutic Approach for an
Overlooked Disorder
Michael Simons and Timo Daniel Vloet
Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, RWTH Aachen University, Germany
Abstract: Objective: Emetophobia is the specifi c fear of vomiting that usually commences during childhood and adolescence. Cognitive behav-
ioral therapy aims to expose patients to vomiting. In this paper, a newly developed metacognitive concept and treatment approach to this disor-
der 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.
Keywords: adolescents, emetophobia, metacognitive therapy, specifi c fear of vomiting
Emetophobie - ein metakognitiver Therapieansatz für eine übersehene Störung
Zusammenfassung: Fragestellung: Emetophobie zählt zu den spezifi schen Phobien und ist die Angst vor dem Erbrechen. Die Kognitive Verhal-
tenstherapie zielt darauf ab, Patienten mit Erbrechen zu konfrontieren. Die vorliegende Arbeit präsentiert ein neu entwickeltes metakognitives
Störungs- und Behandlungskonzept und eine kleine Fallserie. Methode: Drei weibliche Jugendliche mit Emetophobie wurden mit Metakogniti-
ver Therapie (MCT) behandelt. Maße für Angst, Sorgen, Depressivität und Metakognitionen vor und nach der Behandlung werden berichtet. Er-
gebnisse: Alle Patienten gesundeten im Verlauf der 8- bis 11-stündigen Behandlung. Die Werte für Angst, Sorgen, Depressivität und Metakogni-
tionen gingen deutlich zurück. Schlussfolgerungen: MCT könnte eine wertvolle Behandlungsoption für Jugendliche mit Emetophobie sein.
Schlüsselwörter: Emetophobie, Jugendliche, Metakognitive Therapie, spezifi sche Phobie vor Erbrechen
Emetophobia is the speci c phobia of vomiting that, al-
though largely unheard of outside the medical nomencla-
ture, is widely disseminated (Davidson, Boyle& Lauchland,
2007; Vandereycken, 2011; van Hout & Bouman, 2012).
The fears emetophobic patients experience range from mild
concerns to severe panic attacks, precipitating various indi-
vidual psychosocial impairments.
Surprisingly, this phobia often seems to be overlooked
by professionals, and little attention is paid to the (scarce)
scienti c literature (Vandereycken, 2011). The paucity of
attention to this disorder may be exacerbated further by
clinicians’ anecdotal impressions of emetophobia as a
di cult disorder to treat (Maak, Deacon& Zhao, 2013).
In this context, previous surveys cite high dropout rates
and poor treatment responses (Veale& Lambrou, 2006).
Hence, only few reports exist concerning successful ther-
apy of emetophobia. Most data are found in case reports,
and to date no manualized treatment protocols or rand-
omized-controlled studies are available (Bouman& van
Hout, 2006; Maack, Deacon & Zhao, 2013; Moran &
O’Brien, 2005; van Hout& Bouman, 2012; for a review
see Boschen, 2007). The treatment of emetophobia thus
is unstandardized, although several therapeutic ap-
proaches do exist, ranging from hypnotherapy (e. g., Mc-
Kenzie, 1994), interoceptive exposure, and “analog vom-
iting” (McFadyen & Wyness, 1983) to psychotropic
medication (Lipsitz, Fyer, Paterniti& Klein, 2001). Fur-
thermore, most treatment protocols relate solely to
adults, and there are only few studies of minors– which is
surprising as the maximum frequency lie presumably in
childhood and midadolescence (van Hout & Bouman,
Although Boschen (2007) reconceptualized this phobia
in cognitive behavioral terms, the current paper present a - Thursday, September 29, 2016 7:21:44 AM - RWTH Aachen IP Address:
2 M. Simons & T. D. Vloet, Emetophobia
Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2016), 44, 1–10 © 2016 Hogrefe
new, metacognitive model of emetophobia. A small case se-
ries of metacognitive therapy (MCT) is presented, which
preliminary indicates that it may be a sensible alternative
treatment approach in adolescence. A systematic litera-
ture search in Pubmed (search terms: emetophobia OR
vomiting AND metacognitive) found no electronic data-
base for MCT of emetophobia.
According to the International Statistical Classi cation of
Diseases and Related Health Problems (ICD-10; WHO,
1992) and the Diagnostical and Statistical Manual of Men-
tal Disorders (DSM-5; APA, 2013) emetophobia is classi-
ed as a speci c (isolated) phobia (F40.1 and 300.29, re-
spectively). However, the explicit term “emetophobia” is
listed in neither of the classi cation systems. The clinical
symptomatology is multifarious: Some patients have an in-
tense fear of vomiting, while others may be afraid of other
people vomiting in their presence. Nausea is common in
emetophobic patients (Höller, van Overveld, Jutglar &
Trinka, 2013). Associated worries concern the fear of con-
tamination by the vomit, social phobic connotations, or a
sense of shame in case of vomiting in public (van Hout&
Bouman, 2012) as well as the fear of losing control (David-
son, Boyle & Lauchlan, 2007). Price, Veale, and Brewin
(2012) observed an incidence of 81  % in a study of 36 par-
ticipants a ected by multisensory intrusive imagery of
adult (52  %) and childhood memories (31 %) and worst-
case scenarios (“ ash-forwards”) of vomiting (17 %). The
extent of imagery was found to be signi cantly related to
the severity of the phobia. A collection of important cogni-
tive and behavioral processes can be found in Table1.
The a ected individuals employ avoidance strategies
that are often very elaborate (and successful), so that the
last episode of real vomiting frequently lies far back in
time (van Hout& Bouman, 2012). The a ected individu-
als often also exhibit so-called “safety-seeking” behavior
(looking for security signals), selectively focusing their
attention on inner, somatic sensations. Hence, a pro-
nounced focusing on interoceptive stimuli such as nausea
(Hunter& Antony, 2009) and intensive control of expira-
tion dates (Vaele & Lambrou, 2006); they often avoid
eating in a restaurant or visiting somebody with gastro-
intestinal complaints (Bouman& van Hout, 2006). These
individuals frequently exhibit ritualized food intake,
restrictions on certain foods as well as ingestion of
antacids. They usually make sure that a bathroom is
somewhere in close proximity. Female patients with em-
etophobia may even shun or interrupt a pregnancy in or-
der to avoid nausea in the  rst trimester (Veale & Lam-
brou, 2006). The symptomatology often generally causes
severe impairments of psychosocial functioning. In-
creased emetophobic symptoms are associated with
higher levels of functional impairments (Wu, Rudy, Ar-
nold& Storch, 2015).
Table 1. Symptomatology
Emotion Worry Avoidance of Safety behavior Attentional focus
Fear Vomiting School attendance Carrying a plastic bag Interoceptive attention to
gastrointestinal state
Disgust Losing control Breakfast before school Take antinausea medication Try to distract oneself
Shame What others think while
seeing me vomit
Certain foods Checking of sell-by dates Hypervigilance for sick
Eating from buffets/salad bars Keep tight control of body Looking for an escape route
Public transport Keep very still
Long travels Reassuring self
Crowded places Seeking reassurance
Public toilets Frequent handwashing
Being near sick or drunk people
Watching movies with vomiting scenes - Thursday, September 29, 2016 7:21:44 AM - RWTH Aachen IP Address:
M. Simons & T. D. Vloet, Emetophobia 3
© 2016 Hogrefe Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2016), 44, 1–10
Etiology, Comorbid, and
Differential Diagnoses
There is some evidence of associative learning in the etiol-
ogy of emetophobia, with vomiting being associated with
an unrelated life event or an aversive consequence (e. g.,
Veale, Costa, Murphy& Ellison, 2012). However, the etiol-
ogy is relatively understudied (Van Hout & Bouman,
2012), and it is still unclear whether or not emetophobia
can be classi ed as a “primary” or a “secondary” diagno-
sis. On the one hand, the data from case studies indicate
that emetophobia often appears primarily (e. g., Dattilio,
2003; Moran & O’Brien 2005) and comorbid disorders
follow (Lipsitz, Fyer, Paterniti& Klein, 2001). On the other
hand, emetophobia is also frequently interpreted as a co-
morbid disorder by constituting a part of the symptoma-
tology of other anxiety disorders, such as social phobia
(Marks, 1987), agoraphobia (Pollard, Tait, Meldrum, Du-
binsky& Gall, 1996), or panic disorder (Lydiard, Laraia,
Howell& Ballenger, 1986) and hence is more of a second-
ary nature. Therefore, in the penultimate and current edi-
tion of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV, APA 1994; DSM-5, APA 2013) the au-
thors placed in the mixed category of “Speci c Phobia”
(other type). This exacerbates the issue that only little re-
search of emetophobia as a speci c disorder exists.
In a former study, Veale and Lambrou (2006) investi-
gated 100adults with emetophobia and found many paral-
lels to panic disorder (e. g., selective perception, increased
vigilance) on both the behavioral and the associated cogni-
tive processes level. Phenomenological similarities with
obsessive-compulsive disorder (OCD) (e. g., fear of con-
tamination) were also observed. Recent studies found that
the most common comorbid diagnoses were general anxi-
ety 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 diag-
nosed as su ering from anorexia nervosa or hypochon-
driasis. Although emetophobic patients may exhibit ab-
normal eating behavior and are underweight, their
symptomatology is obviously a consequence of feared
nausea, not of the desire to lose weight. 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 signi cant symptomatic over-
lap 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 check-
ing behavior and reassurance-seeking with OCD pa-
tients, this again is solely restricted to associations with
Only few studies have examined the prevalence of emeto-
phobia. The disorder usually commences during child-
hood and adolescence. The a ected individuals are mostly
females, and course of the disorder is often chronic. An
earlier study by Philips (1985) found prevalence rates of
3.1 % for men and 6 % for women in the USA. A German
study reported a point prevalence of 0.2 % and 0.1 %, re-
spectively (Becker et al., 2007). More recently, an epide-
miological study revealed a point prevalence of emetopho-
bic symptomatology (without assessment of DSM-5
criteria) of about 9 % in adults in the Netherlands. Females
were four times more likely to be a ected than males (van
Hout& Bouman, 2012).
Veale et al.’s (2015) sample of 83 cases included 8 youths
(≤ 17 years old). With respect to the total sample, the mean
age of onset of becoming aware of this fear was 8.2 years
(SD 5.21), while the mean age of onset of seeing this fear as
a problem was 14.8 years (SD 7.89). This is comparable to a
German-speaking sample, in which the fear of vomiting
generally started in childhood (M 9.5 years, SD 6.4; Höller,
van Overveld, Jutglar& Trinka, 2013).
Cognitive Behavioral Treatment
Cognitive behavioral treatment approaches consider the
avoidance of vomiting as well as of stimuli associated with
vomiting as the primary factors maintaining the problem.
Thus, there are di erent ways of utilizing exposure thera-
py for emetophobia (Boschen, 2007).
First, exposure could focus on vomiting itself, whereby
the patient is encouraged to vomit, using fake vomiting
and the provocation of vomiting by the ingestion of emet-
ics. Second, exposure could focus on stimuli such as vom-
iting by watching movie scenes or passing streets with bars
where drunken people tend to vomit. Third, interoceptive
exposure could be conducted by eating disgusting meals.
In a recent paper, Maack, Deacon, and Zhao (2013) pre-
sented a case study with graduated exposure to vomiting
in the course of  ve prolonged sessions lasting from 1 to 3
hours each. At the beginning of the therapy, the patient - Thursday, September 29, 2016 7:21:44 AM - RWTH Aachen IP Address:
4 M. Simons & T. D. Vloet, Emetophobia
Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2016), 44, 1–10 © 2016 Hogrefe
had to watch vomiting scenes with an increasing potential
of eliciting disgust. In the following sessions, the patient
had to overeat on medium rare burgers and french fries,
fake vomiting, and  nally actually vomit. Cognitively ori-
ented approaches in turn help patients to estimate putative
dangers more realistically, i. e., patients can learn that nau-
sea does not necessarily lead to vomiting, and that nausea
may in fact be a sort of “false alarm.” By using Socratic dia-
logues and behavioral experiments patients can be helped
to reality test their mistaken beliefs.
In our own experience, emetophobic patients are espe-
cially di 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 interven-
tion 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 pro-
portion actually su ers from emetophobia. Thus, the start-
ing point of a metacognitive model posits that emetopho-
bic patients tend to worry permanently about vomiting
although they rarely actually vomit. We propose to de ne
“worry” instead of “disgust” as the crucial feature of eme-
tophobia. This paper presents a new treatment approach
that aims to reduce excessive worrying.
Metacognitive Therapy
Wells (1997; 2009) originally developed metacognitive
therapy (MCT) for the treatment of GAD, which is charac-
terized by excessive worry. MCT was later applied to other
anxiety disorders (social anxiety disorder, hypochondria-
sis, OCD, posttraumatic stress disorder) and depression.
MCT has its roots in cognitive therapy (CT), though con-
trary to the latter it does not focus on the content of
thoughts and beliefs, but on cognitive processes. MCT
does not try to change an individual worry, but rather to
reduce the process of excessive worrying. From a meta-
cognitive point of view, the following cognitive, attention-
al, and behavioral processes are suggested to uphold
1. Excessive worry, such about possible vomiting.
2. Interoceptive focus of attention on the gastrointestinal
state, especially by searching for possible early signs of
3. Maladaptive coping strategies, especially the avoidance
of school attendance, traveling by bus, and certain foods
as well as safety behaviors like seeking reassurance from
parents or carrying around a plastic bag.
Positive and negative metacognitive beliefs both initiate
and maintain these processes. Positive metacognitive be-
liefs focus on reasons to initiate these processes, like the
• “My thoughts are important, therefore I have to focus
on them.”
“Worrying helps me cope and be prepared.”
“I have to be aware of signs of nausea in order to reach
the bathroom in time.
Avoiding school helps me prevent nausea and
Negative metacognitive beliefs deal with the uncontrolla-
bility and danger of worrying, like the following:
“I cannot stop worrying.”
“I could go crazy with worry.”
The metacognitive model of emetophobia is depicted in
The following presents a small case series of MCT.
To illustrate the metacognitive treatment of emetophobia,
we present a case series of three female adolescents and
their data before and after therapy.
The following case series focuses on three female patients
who were consecutively referred to our outpatient child
and adolescent psychiatric clinic. All patients ful lled the
ICD-10/DSM-IV criteria for the speci c phobia of vomit-
ing and additionally met criteria for at least one comorbid
disorder, such as OCD, somatization disorder, and depres-
sion (for details, see Table3). The diagnoses were based on
a semistructured clinical interview (Schedule for A ective
Disorders and Schizophrenia for School-Age Children;
Kaufman et al., 1997). All patients stated that the fear of
vomiting was their main problem; they di ered regarding
the duration of the disorder before treatment (from
3months to 2years; see Table3). Two of the patients were
treatment naïve, while the other indicated having dropped
out of an unsuccessful psychotherapy where she was in-
structed to breathe slowly and mindfully. No patient had
received medication. - Thursday, September 29, 2016 7:21:44 AM - RWTH Aachen IP Address:
M. Simons & T. D. Vloet, Emetophobia 5
© 2016 Hogrefe Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2016), 44, 1–10
A small set of standardized and widespread self-report
measures assessing di erent dimensions of anxiety, de-
pression, and metacognitions was administered. The
Spence Children’s Anxiety Scale (SCAS; Spence, 1998) is a
multidimensional measure of anxiety, comprising the fol-
lowing subscales: panic/agoraphobia (PA), separation anx-
iety (SA), social phobia (SP), physical injury fears (PIF),
obsessive-compulsiveness (OC), and generalized anxiety
(GA). The 38 items can be rated on a 4-point scale ranging
from never (0) to always (3). Thus, the total score poten-
tially ranges from 0 to 114. Spence (1998) found a high in-
ternal consistency for the total score (Cronbach’s α= .92)
and adequate internal consistencies for the subscales (α=
.60–.82). Test-retest reliability (6 months) for the total
scale was rtt= .60. According to internet data (http://www., the average score of adolescent girls is
27.88 (SD 15.32). Furthermore, the following subscale
scores were used: general anxiety as a measure of worry
(M 6.31, SD 3.34), panic/agoraphobia as a measure of in-
tense body-focused anxiety and corresponding avoidance
behavior (M 3.60, SD 3.94), social phobia as a measure of
social concerns (M 6.85, SD 3.52), and obsessive-compul-
sive symptoms (M 4.29, SD 3.45) referring to Veale, Hen-
nig& Gledhill (2015) proposing to imbed emetophobia in
the OCD spectrum. Beside the raw scores, T scores in ref-
erence to Spence (1998), as well as internet sources were
included in the assessment.
As a measure of depression, the T scores of the German
Child Depression Inventory (Depressionsinventar für
Kinder und Jugendliche; DIKJ; Stiensmeier-Pelster, Schür-
mann& Duda, 2000) or– for the 17-year-old patient– the
German simpli ed version of the Beck Depression Inven-
tory (BDI-V; Schmitt et al., 2006) were applied. Both
measures show very good internal consistency with Cron-
bach’s α = .91 in German samples (DIKJ; Schmitt et al.,
2006; Stiensmeier-Pelster et al., 2000).
Metac ognition:
Worrying and focusing on signs of nausea keeps me
I c a nnot s top worrying.
Fear of vomiting
Naus ea and fe a r of na us ea .
Disgust at some meals.
View of s elf / world:
I am vulnerable and
S ome me als are
W orry:
W hat if I am sick?
W hat if I have to thro w up?
worry ing to v o mit.
Attention focus ing on s igns of na us ea .
Checking of expire dates.
Avoiding some food and activities (e.g.
riding the bus)
Figure 1. Metacognitive model
of emetophobia - Thursday, September 29, 2016 7:21:44 AM - RWTH Aachen IP Address:
6 M. Simons & T. D. Vloet, Emetophobia
Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2016), 44, 1–10 © 2016 Hogrefe
To assess metacognitive beliefs, we utilized the Meta-
cognitions Questionnaire for Adolescents (MCQ-A; Cart-
wright-Hatton, Mather, Illingworth, Brocki, Harrington&
Wells, 2004). The MCQ-A is a self-report questionnaire
for adolescents aged 13 to 17, consisting of 30 items and 5
subscales containing 6 items each, which are rated on a
4-point scale ranging from do not agree (1) to agree very
much (4). The 5 subscales are (1) positive beliefs about wor-
ry (POS), (2) negative beliefs about uncontrollability and
danger of worrying (UD), (3) beliefs about superstition,
punishment and responsibility (SPR), (4), cognitive self-
consciousness (CSC), and (5) (low) cognitive con dence
(CC). The total score is the sum of all statement scores, al-
lowing for total scores between 30 and 120; the scores of
the subscales lie between 6 and 24. Zahn (2015) found
very good internal consistencies for the total score with
Cronbach’s α= .91 in a clinical German sample.
As a last step data of possible school absenteeism were
Treatment started with an individualized case conceptual-
ization containing the aforementioned crucial processes
and metacognitive beliefs, followed by socializing the pa-
tient to the treatment model. The therapist pointed out the
important di erence between worrying thoughts, on the
one hand, and the worrying process answering to these
thoughts, on the other hand. Whereas the latter thinking
process is controllable, the former thoughts are uncontrol-
lable and often intrusive. Thus, attempts to control and
suppress worrying thoughts are bound to fail and often
lead to a rebound of the worrying thoughts (Wegner, Sch-
neider, Carter& White, 1987). Instead, patients were en-
couraged to try and see these thoughts as unimportant,
e. g.: “You’re saying that you haven’t vomited for three
years, but every day you worry that you could vomit. Do
you think this thought is an important message to you or is
it just a thought?” Instead of  ghting, arguing, or analyzing
this thought, the therapist suggests experiencing the
thought nonreactively and then letting it go (“detached
mindfulness”). The telephone metaphor helped to further
understand this new strategy: “You cannot control wheth-
er the telephone rings or not, but you can decide whether
to pick up the phone or just let it ring. Likewise, you do not
decide whether this worrying thought pops into your mind
or not, but you can learn that you do not have to answer to
this thought.”
Subsequently, the therapy focused on modifying nega-
tive metacognitive beliefs regarding the asserted uncon-
trollability of worrying, by practicing detached mindful-
ness and by postponing the worry process. Every time the
patient had a worry thought, she could say to herself: “This
is just a thought, I’ll take care of it later.” She then had the
option of reserving 10 minutes in the evening to deal with
these thoughts if she wanted to. It was recommended to
determine the beginning and the end of this “worry time”
in advance.
A further strategy to foster the controllability of worry-
ing is called “stop and go.” The therapist asked the patient
rst to bring the worry thought to mind and then to initiate
the worry process. After about 15 seconds the therapists
said: “Stop!” and asked the patient to hold the worry
thought in mind without processing it further. This can be
compared to watching a DVD and then pressing the pause
button. After 15 seconds the patient was prompted to pro-
ceed with worrying (“as hard as you can”) and again after
further 15 seconds to stop worrying, while keeping the
thought in mind. This exercise often markedly reduced
negative metacognitive beliefs about the uncontrollability
of worrying in a very short period of time. Interestingly,
after the successful reduction of these uncontrollability
beliefs, no patient stated any negative beliefs about the
possible dangers of worrying anymore; thus, no further in-
terventions to reduce these beliefs were needed.
After reducing the negative metacognitive beliefs, the
therapy aimed at challenging positive beliefs about worry-
ing and threat monitoring, e. g., through the use of Socratic
dialogues: “You say that you have to worry in order to be
prepared. How is it important that you prepare yourself
permanently for possible vomiting when you do not even
vomit afterwards? How does it a ect your nausea when
you try to detect early signs of it?”
Afterwards, the patients learned to reduce the height-
ened interoceptive focus of attention and to direct focus
toward external a airs instead, e. g., the social environ-
ment, school lessons, or current tasks. The next step aimed
at removing avoidance and safety behaviors, because they
encouraged the overestimation of thoughts: “When you
dispense with certain foods and meals because of your
worries, do you treat these worries as facts or ‘just as
thoughts’?” and “If you knew these thoughts were mean-
ingless, would you have any reason for not riding the bus?”
In the case that avoidance referred to very essential as-
pects of daily living, therapy focused on reducing these
behaviors early on in the treatment. In our sample, emeto-
phobia resulted repeatedly in (total or partial) school ab-
senteeism. Thus, we aimed at gradually increasing school
attendance relatively early in the treatment. If the treat-
ment had failed to increase school attendance, inpatient
treatment would have been recommended.
At the end of the therapy, residual symptoms were re-
moved and strategies for relapse prevention initiated.
Therapist and patient worked together on writing a thera-
py blueprint that contained a comparison of crucial think- - Thursday, September 29, 2016 7:21:44 AM - RWTH Aachen IP Address:
M. Simons & T. D. Vloet, Emetophobia 7
© 2016 Hogrefe Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2016), 44, 1–10
ing and behavioral, attentional processes before and after
therapy, as well as a new plan for information processing
(see Table2).
As can be seen in Table3 and Figure2, before treatment
measures of fear (SCAS total score), worry (SCAS GA),
panic/agoraphobia (SCAS PA), obsessive compulsive
symptoms (SCAS OC), and depression were clinically rel-
evant, while social anxiety (SCAS SP) was not. In one of
the cases, school absenteeism lay at 50 %, in another at
100 %. Metacognition scores were somewhat elevated, es-
pecially beliefs concerning uncontrollability and the dan-
ger of worrying.
After treatment, all anxiety, depression, and metacogni-
tion scores fell substantially and returned to normal. Thus,
in all three patients the treatment succeeded in reducing
fear of vomiting, worrying, and metacognitions. In cases
of partial or total school absenteeism, school attendance
was restored within a rather short time. The entire treat-
ment was quite short, with 8 to 11 sessions on a predomi-
nantly weekly basis, lasting each about 40 to 50 minutes.
The treatment was well accepted, and none of the three
patients dropped out of therapy prematurely.
Clinical Signifi cance
To ensure that any occurring clinical signi cant change
was reliable, Jacobson & Truax (1991) introduced the reli-
able change index (RCI), which is calculated by taking the
di erence between pre and post scores divided by the
standard error of the di erences (RCI= xpre– xpost/SDi ). If
the RCI is greater than 1.96, then the change is accepted as
reliable (p< .05). For every patient the RCI was calculated
regarding the primary outcome measure (SCAS total) and
found greater than 1.96; thus, the improvements can be
determined as reliable.
Table 2. New plan
Trigger: “What if I have to vomit?“
Old Plan New Plan
Thinking: concerned with this thought, consider them as important
and worried about it
Thinking: ignore the thought, it’s just a thought
Behavior: avoid going to school, avoid situations with many peop-
le and places with no chance of leaving immediately, avoid eating
outside of home (e. g., in restaurants)
Behavior: go to school, stay in places and rooms with many people, go
to restaurants
Attention: to signs of nausea, breathing (as recommended by my
former therapist)
Attention: to people around me, school lesson, teacher, TV shows …
Reframe: I’ve learned to take thoughts less seriously and to provoke my fears. It’s not about vomiting, but about worries.
Figure 2. T scores of anxiety
and depression pre and post
treatment for each patient.
Note: SCAS= Spence Chil-
dren’s Anxiety Scale, DIKJ=
Depressionsinventar für Kinder
und Jugendliche (Child De-
pression Inventory), BDI= Beck
Depression Inventory - Thursday, September 29, 2016 7:21:44 AM - RWTH Aachen IP Address:
8 M. Simons & T. D. Vloet, Emetophobia
Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2016), 44, 1–10 © 2016 Hogrefe
Before treatment, emetophobic patients scored high in
anxiety measures (including, but not exclusively, OC
symptoms) as well as measures of depression and meta-
cognition. These very preliminary results suggest that
emetophobia is a broad problem with overlappings with
OCD as well as with panic disorder, generalized anxiety,
and, to a lesser extent, social anxiety. High scores of de-
pression con rm that this phobia is highly distressing for
After treatment, these clinical scores and metacognition
scores normalized. With regard to the MCQ-A, the great-
est di erence between pre and post scores were found in
the subscale “negative beliefs about uncontrollability and
danger.” This emphasizes the premise of MCT that these
metacognitive beliefs are the most in uencing beliefs
maintaining the condition and hence should be addressed
and changed in therapy. All patients succeeded in a rather
short time; no forced exposure to vomiting was needed to
gain this success. The treatment was very well accepted by
the patients. The results suggest that MCT may e ectively
be applied to the treatment of emetophobia.
The Difference Between Metacognitive
and Cognitive Behavioral Therapy
In Germany, MCT is often considered an extension of
CBT, i. e., MCT interventions are added as a further mod-
ule to CBT, for example, of GAD (e. g., Becker& Margraf,
2007). Whereas from a CBT point of view this seems rea-
sonable, from a metacognitive angle the main metacog-
nitive interventions are incompatible with CBT. The main
di erence is that CBT strives to discuss the content of
the worry thoughts and to expose the patient to these
thoughts. In contrast, MCT views these thoughts as unim-
portant, meaningless, passing events in the mind. They
are best left alone. Hence, whereas the cognitive therapist
might challenge the patient’s beliefs by saying: “What is
the evidence that you might vomit at school?”, the meta-
cognitive therapist would ask: “How helpful is it to think
Table 3. Case series: sample (all female) and measures pre and post
Case A B C
Age 15 14 17
Comorbidities OCD, social anxiety, somatization Depression Somatization
Duration of disorder 3 months 2 years 5 months
Sessions 11 8 11
Measures Range Pre Post Pre Post Pre Post
SCAS total (T) 0–114 55 (66) 15 (41) 77 (78) 21 (46) 67 (70) 11 (37)
SCAS GA (T) 0–18 9 (60) 1 (40) 16 (80) 3 (42) 14 (66) 4 (43)
SCAS PA (T) 0–27 9 (64) 1 (45) 21 (87) 4 (55) 21 (87) 3 (50)
SCAS SP (T) 0–18 8 (55) 5 (48) 10 (60) 3 (43) 11 (63) 2 (42)
SCAS OC (T) 0–8 13 (70) 0 (40) 12 (69) 6 (55) 6 (55) 1 (40)
RCI 2.07 2.90 2.90
CDI/BDI T 70 42 75 41 71.5 41.4
MCQ-A total 30–120 62 34 83 44 68 37
MCQ-A POS 6–24 11 6 7 7 6 6
MCQ-A UD 6–24 16 8 23 10 24 9
MCQ-A SPR 6–24 12 7 21 8 17 7
MCQ-A CSC 6–24 13 7 18 12 13 8
MCQ-A CC 6–24 10 6 14 7 8 7
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M. Simons & T. D. Vloet, Emetophobia 9
© 2016 Hogrefe Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2016), 44, 1–10
that much about vomiting at school? Could you try to re-
duce this worrying?”
Similarities between MCT and CBT lie in the recom-
mended estimation of the worry about vomiting as mean-
ingless (MCT) or as a “false alarm” (CBT). In fact, the
“false alarm” metaphor was previously used in this MCT
approach as well, until it became clear that a patient had
utilized this as a self-reassurance strategy: Every time she
felt signs of upcoming nausea she told herself repeatedly:
“This is just false alarm.” Interestingly, she did not think
this to be very helpful. So the therapist asked her: “If you
were to take these sensations as meaningless, would you
have to say again and again to yourself that it is just a ‘false
alarm’? And how often would you have to focus your atten-
tion on this possibly upcoming sensation then?”
Because avoidance behavior maintains the phobic
symptoms, exposure is as much key in MCT as in CBT.
Note, however, that the goal of exposure di ers in MCT
and CBT: MCT does not aim at the habituation of feelings
of fear and disgust, but rather at metacognitive change.
The main question is: “If you knew that sensations of nau-
sea and worries were meaningless, to what extent would
you deal with them and avoid going to school?” Therefore,
MCT and CBT di er noticeably in the way exposure is
In MCT, neither the initial activation of fear and disgust
nor the habituation of these feelings is pursued, which in
our experience makes the exercise more tolerable for the
patient. Nevertheless, exposure is indispensable in order
to generalize progress in therapy, especially regarding cog-
nitive and attentional strategies. Two of our patients
avoided riding the bus in order to prevent nausea and the
fear of vomiting. In traditional behavioral exposure thera-
py, they would have been instructed to ride the bus in or-
der to reduce fear and nausea. Instead, we instructed them
to ride the bus while addressing worries through detached
mindfulness and focusing their attention outwardly on
other people in the bus and the external landscape.
The following two interventions, which weren’t used in
the cases presented here, should be considered in the fu-
ture: the “attention training technique” (ATT; Wells, 1990;
2009) and “a ect labeling.” The ATT is a metacognitive
intervention that aims at gaining more  exibility regarding
the focus of attention. Just like panic patients, patients
with emetophobia show a heightened attentional bias to-
ward physical symptoms resulting in an increase of notice-
able bothersome sensations. By focusing the attention on
external noises, the ATT helps to reduce this negative at-
tentional bias. “A ect labeling” is a strategy in which pa-
tients are asked to verbalize their negative feelings during
the exposure exercise (Craske, Treanor, Conway, Zboz-
inek& Vervliet, 2014). Preliminary  ndings suggest that,
for example, in spider phobia, a ect labeling (“Sitting in
front of the ugly spider makes me very nervous”) was ef-
fective in reducing physical stress symptoms (skin con-
ductance response), while cognitive reappraisal (“Sitting
in front of the little spider is not dangerous for me”), dis-
traction, and exposure alone were not (Kircanski, Lieber-
man& Craske, 2012). In the metacognitive procedure pre-
sented above, a ect labeling could easily be combined
with detached mindfulness (“This is just a thought– this
thought scares me and now I will leave this thought
This study has three principal limitations. First, the gener-
alizability of the e ects of MCT is extremely limited by the
simple pre-post design (i. e., no multiple baseline and no
follow-up data) and by the small sample of rather homoge-
neous patients treated (with regard to age and sex). Sec-
ond, the outcome of treatment relied solely on self-report
measures, so that objective and independent clinician-ad-
ministered assessments are missing. Finally, the delivery
of this brief treatment relied on a single therapist. The ef-
fectiveness as well as the feasibility of MCT delivered by
less experienced metacognitive therapists remains to be
This case series shows for the  rst time that MCT may be a
valuable new treatment option for emetophobia. This pa-
per should stimulate further studies on the multifarious
and sometimes OCD-like symptomatology of emetopho-
bia, the role of metacognitions in maintaining and treating
this condition, and of course the randomized and con-
trolled evaluations of MCT.
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Manuscript submitted. 25.03.2016
Accepted after revision: 30.05.2016
Confl icts of interest: No confl icts of interest
exist. Article online: 29.09.2016
Dr. phil. Dipl.-Psych. Michael Simons
Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes-
und Jugendalters
Uniklinik RWTH Aachen
Neuenhofer Weg 21
52074 Aachen
Deutschland - Thursday, September 29, 2016 7:21:44 AM - RWTH Aachen IP Address:
... One study showed that both POS and NEG decreased significantly after group-based MCT treatment in a sample of 44 children with a primary GAD-diagnosis [52]. Simons and Vloet [81] examined MCT in three female adolescents diagnosed with emetophobia in their single-case study, and reported a descriptive reduction in POS in one of the three girls, while the values remained stable in the other two. In contrast, a descriptive decrease in NEG was observed in all three patients. ...
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Metacognitive beliefs have repeatedly proven to play a role in anxiety disorders in children and adolescents, but few studies have investigated whether they change after cognitive behavioral therapy. This longitudinal intervention study explores whether positive and negative metacognitive beliefs in particular change after exposure-focused treatment, and if metacognitive changes predict reductions in anxiety symptoms. A sample of 27 children between 8 and 16 years of age with a primary diagnosis of specific phobia, separation-anxiety disorder or social phobia completed assessments of anxiety symptoms, metacognitive beliefs, worry and repetitive negative thoughts before and after 11 sessions of intensified exposure treatment. Metacognitive beliefs did not change significantly after intensified exposure, but post-hoc power analysis revealed a lack of power here. Change in negative metacognitive beliefs correlated with a change in anxiety symptoms, but did not independently contribute as a predictor variable. Differences between subsamples showed that patients with separation-anxiety disorder scored higher on negative metacognitive beliefs than those with specific or social phobia. Consideration of metacognition, and negative metacognitive beliefs in particular could help us further improve the understanding and treatment of anxiety disorders in children and adolescents and should therefore receive more attention in psychotherapy research.
... After 36 years of theory and research, MCT is still in its developmental stages, and much remains to be explored, such as applications to occupational settings, physical illnesses, severe mental illnesses, addiction, and children and adolescents. While research has begun in these areas (i.e., Caselli et al., 2018;Esbjørn et al., 2018;Simons & Kursawe, 2019;Simons & Vloet, 2016;Wells et al., 2020;Wells et al., 2021), large-scale trials, mirroring those conducted in adult mental health, are a task for the future. ...
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Metacognitive therapy (MCT) is proving to be an effective treatment for anxiety and depression with effects that may exceed CBT. It has been described as a paradigm shift in psychotherapy in its theory-driven cognitive science approach and systematic development and evaluation. MCT was developed by Adrian Wells based on an information processing theory, the Self-Regulatory Executive Function model by Wells and Matthews. MCT theory formulates psychological disorders as sharing common causal factors under the influence of metacognition, representing a particular top-down model of biases in cognitive regulation. A key clinical implication was that a core set of interventions could be developed to impact a wide range of symptoms and disorders. In this paper, we trace the historical development of MCT and the major studies that informed theory and practice with the aim of introducing clinicians and researchers to this area and to understand why the metacognitive approach has developed into a treatment that is proving to be potentially more effective than current gold-standard treatments. In doing so, we will draw out the distinctive features of the approach and explore how this might offer a blueprint for scientific advancement in clinical psychology and psychotherapy.
... Three studies included a retest-measurement to assess test-retest correlations for validating different questionnaires [53][54][55]. Nine studies followed a longitudinal design in the form of intervention studies with prepost-(and follow-up) measurement points[26, [56][57][58][59][60][61][62][63]. ...
Background: The metacognitive model of generalized anxiety disorder identifies three forms of metacognition: Positive metacognitive beliefs about worry (POS), negative metacognitive beliefs about worry (NEG), and meta-worry. Though this model was originally developed relying on adult samples, it has since been applied to children and youth in different studies, and results mostly support its validity for this group. As the roles of POS, meta-worry, and age-effects do not appear to be fully clarified for children and adolescents yet, an integration of studies on children and adolescents and the metacognitive model is both timely and worthwhile. Aim: To summarize the current research on relationships, age-effects, and measurements for POS, NEG, and meta-worry in childhood and youth. Methods: We carried out a literature search in the electronic databases PsycINFO, PubMed, PSYNDEX, and ERIC in 2017 and updated in 2020. Empirical research in German or English language on metacognition was included with child and adolescent samples diagnosed with anxiety disorders or healthy controls if POS, NEG, or meta-worry were measured. Studies were included for meta-analysis if they reported correlations between these metacognitions and anxiety or worry. Consensus rating for eligibility was done for 20.89% of full-texts with 90.32% agreement. Risk of bias was assessed with the appraisal tool for cross-sectional studies and consensus rating of appraisal tool for cross-sectional studies for 20.83% of included studies attaining agreement of intraclass correlation = 0.898. Overall, correlations between metacognitions, anxiety and worry were calculated with RevMan 5.4.1, assuming random-effects models. Meta-regressions with mean age as the covariate were performed via the online tool MetaMar 2.7.0. PROSPERO-ID: CRD42018078852. Results: Overall, k = 763 records and k = 78 additional records were identified. Of those, k = 48 studies with 12839 participants were included and of those, k = 24 studies were included for meta-analysis. Most studies showed consistent NEG correlations with worry and anxiety, as well as higher values for clinical than for non-clinical samples. POS findings were less consistent. Meta-analysis revealed large effects for NEG correlating with worry and anxiety, small to medium effects for POS correlating with worry and anxiety, as well as small to medium effects for POS correlating with NEG. Meta-regressions did not reveal mean age as a significant covariate. Meta-worry was assessed in only one study. We identified eight questionnaires and one interview-format that assess metacognition about worry in children and adolescents. Conclusion: POS and NEG are measurable from the age of seven upwards and correlate with anxiety and worry without influences by age. Meta-worry requires further investigation.
... Fallstudien zeigen eine Wirksamkeit bei einer Vielzahl psychischer Erkrankungen (z. B. [9,11,15,16]) ▪ Mit der metakognitiven Therapie liegt ein Behandlungsmanual vor, welches im Falle von nicht komplex-multimorbid erkrankten Patienten bereits nach 5-10 Sitzungen eine signifikante Symptomreduktion herbeiführen kann [2]. ▪ Außerdem gibt es Hinweise dafür, dass die Methode ggf. ...
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The term emetophobia (i.e., a fear of vomiting) exists as rather an elusive predicament, often eluding conventional treatment. The present study involved 149 participants, consisting of 51 emetophobics, 48 phobic controls (i.e. those who suffered from a different phobia), and 50 nonphobic controls. Participants were administered the Rotter (1966) Locus of Control Scale and the Health Locus of Control Scale by B.S. Wallston, Wallston, Kaplan, and Maides (1976). Significant differences were found among the three groups; specifically, that emetophobics had a significantly higher internal Locus of Control Scale score with regard to both general and health-related issues than did the two control groups. It is suggested that vomiting phobics may have a fear of losing control, and that their vomiting phobia is reflective of this alternative, underlying problem. More research is required to explore the association between emetophobia and issues surrounding control; however, the current study suggests that it may be helpful for therapists to consider this aspect when treating a patient with vomiting phobia.
An emetic syrup was titrated according to a reduction schedule in order to recreate graduated levels of nausea in the exposure of a 34-year-old female who developed the fear of nausea and emesis (vomiting) after vomiting on stage during a piano recital. In this particular case, the patient was taught breathing retraining and anxiety reduction techniques such as double swallowing, in addition to some imagery as a desensitisation procedure to avoid reacting to nausea by vomiting. Results in similar case designs suggest that, at times, artificial methods such as the above may be used to create variations of a situation that cannot always be duplicated through pure imaginal exposure or during in vivo exposure, especially when the stimulus involves certain physiological responses such as a gastric regurgitation. A two-year follow-up yielded no indication of relapse and a full return to pre-baseline status.
Emetophobia, or a specific phobia of vomiting, is an underresearched disorder characterized by extensive avoidance and safety-seeking behaviors. Extant literature has primarily focused on online support groups and qualitative investigations, thereby limiting the generalizability of results. As such, this study sought to examine the clinical correlates, phenomenology, and impairment related to emetophobia in 436 undergraduate students. About 5% of the sample exhibited significant emetophobia symptoms (n = 21), with all participants in this subsample reporting an age of onset prior to adulthood. In addition, participants' most distressing aspects of emetophobia were reported to be the somatic sensations of vomiting and the social impact of the disorder. For the entire sample (N = 436), emetophobia symptoms were associated with heightened anxiety, somatization, and depressive symptoms. In addition, functional impairment was observed across home/family, school/work, and social domains of life, even after controlling for the effects of anxiety and depressive symptoms. Detailed results and implications of the findings are discussed, and suggestions for future studies are presented.
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.