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La fobia specifica per il vomito: una rassegna sistematica internazionale.

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Abstract

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.
Iacolino C.*, Cervellione B.*, Ferracane G.*, Modesto G.*, Salamone R.A.*, Lombardo E.M.C.*
*Università degli Studi di Enna “Kore”
Le classificazioni diagnostiche ufficiali considerano l’emetofobia come una fobia specifica (isolata) (APA, 2013; ICD-10, 1992). Tale disturbo
d'ansia oltre ad essere poco studiato in letteratura, risulta essere anche poco compreso nella società odierna (Boschen, 2007; van Hout & Bouman,
2012). La fobia specifica per il vomito (o SPOV) è considerata un problema cronico con esordio precoce (Ve ale et al., 2013; Wu et al., 2017),
producendo un disagio clinicamente significativo con la compromissione del funzionamento sociale, affettivo, lavorativo e scolastico. La
sintomatologia è multiforme: la paura del vomito può essere scatenata non solo dalla vista di un'altra persona che vomita ma anche da nausee o
preoccupazioni per la contaminazione del cibo.
INTRODUZIONE
Valutazione degli articoli per l’inserimento nella rassegna.
Criteri di esclusione:
1.Articoli non completati perché ancora in fase di sviluppo
2.Tutti gli articoli che differivano dalle ipotesi di partenza
3.Tutti gli articoli su riviste non indicizzate
4.Rassegne sistematiche della letteratura
5.Standardizzazione degli strumenti
Numero di articoli selezionati:
N = 401
Database di ricerca:
EBSCO
(Education Research Complete;
PsycArticles; Psychology and Behavioral
Sciences Collection; SocIndex)
PubMed
Scopus
Numero di doppioni
(eliminati):
n = 44
Numero di abstract e articoli full text
selezionati per la revisione:
n = 134
Numero di articoli
inseriti nella rassegna:
n = 23
COMORBIDITÀ E DIAGNOSI DIFFERENZIALE
La diagnosi di disturbo emetofobico è molto difficile da
determinare in quanto la condizione si presenta con sintomi che si
osservano anche nel DOC, disturbo di panico, agorafobia, disturbo
d’ansia generalizzato (Boschen, 2007; Ve ale , 2009; Va n Hout &
Bouman, 2012). Oltre alle condizioni che presentano una
condizione simile all’emetofobia, anche i soggetti con disturbo
d’ansia mostrano elevati tassi di comorbidità con i disturbi
dell’umore, da uso di sostanze e disturbi della personalità (Brown
& Barlow, 1992). In Vea l e 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 (Vea l e 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. lavaggio continuo delle mani). Tali comportamenti
vengono messi in atto come strategia controllante. Tuttavia, uno
dei problemi più gravi in tale disturbo è quello riferito alla sfera
alimentare; molte sono in effetti, le probabilità che un emetofobico
tenda a sviluppare delle restrizioni alimentari, spesso causate da
traumi riferiti al vomito, le quali talvolta, sfociano spesso nel
cosiddetto “Disturbo evitante/restrittivo dell’assunzione di cibo”.
Riguardo alla variabile età di esordio, la letteratura, pone in evidenza come il
range di età si collochi tra i 13 e i 18 anni (Wu, Rudy, Arnold & Storch, 2015;
Hӧller et al, 2013; Lipsitz et al., 2001; Price et al., 2012). La variabile differenza
di genere, risulta essere, in questo quadro sintomatologico, molto importante. La
letteratura dimostra che le donne risultano esserne più colpite, intaccando la
sfera relazionale, sociale e affettiva. Molte di loro, addirittura, evitano la
gravidanza per la paura della tipica nausea e vomito trimestrali (Ve al e &
Lambrou, 2006; Price, Ve a l e &Brewin, 2012). Altro fattore importante, viene
messo in luce nello studio di De Jongh (2012), in merito alla presenza di
problemi di attaccamento dei soggetti emetofobici. Attraverso le ricerche,
l’autore evidenzia la presenza di attaccamenti di tipo insicuro dovuti a una non
disponibilità emotiva e fisica dei genitori. Continui rifiuti ed esperienze
altamente deficitarie di accudimento, portano i soggetti a trasformare queste
relazioni fallimentari in qualcosa di più controllabile e meno dannoso: le fobie,
un mezzo per scaricare la tensione ed il dolore causato da tali esperienze
spiacevoli, al fine di auto proteggersi dall’eccessiva sofferenza provata.
FATTORI DI RISCHIO E DI PROTEZIONE: ATTACCAMENTO,
ETA DI ESORDIO E DIFFERENZA DI GENERE
TRATTAMENTO
Gli studi effettuati da Bougsh, Moeller e O’Brien (2018), affrontano
il quesito di quali siano le terapie migliori da applicare. I risultati
pongono in evidenza l’efficacia del trattamento ACT (tecnica
cognitivo comportamentale di terza generazione, la quale utilizza
esercizi di Mindfulness e defusione). De Jongh (2012) propone un
trattamento basato sull’EMDR. Nel caso di una sua paziente
emetofobica, dopo solo quattro sessioni di trattamento, al re-test
effettuato con la scala sintomatologica, dei problemi psicologici e
psicopatologici (Derogatis, 1994), èemerso come le sessioni di
EMDR, focalizzate sulla rievocazione di ricordi di eventi passati,
risultano essere efficaci tanto quanto la sola CBT.
CONCLUSIONI
Dato l'impatto espansivo dell'emetofobia su più domini di vita, è plausibile che i
comportamenti di evitamento e la conseguente compromissione funzionale
portino a un'esistenza più isolata, dando origine a una vasta gamma di sintomi di
interesse clinico. La letteratura analizzata evidenzia che i sintomi più elevati di
emetofobia risultano essere associati a livelli più alti di compromissione
funzionale in tutti i domini della vita. La rassegna mette in luce che sfuggire alle
situazioni che provocano ansia non solo impedisce all’emetofobico di funzionare
in modo adattivo ma perpetua anche il ciclo dell'ansia impedendo allo stesso di
affrontare le situazioni temute. Dunque, mentre i comportamenti di monitoraggio
delle minacce servono a rinforzare il ciclo negativo dell'ansia, l'evitamento
completo impedisce all'individuo di essere fisicamente presente in varie
situazioni, con conseguente aumento della menomazione. L’emetofobia può
avere sequele uniche (e.g., complicazioni mediche a causa di restrizioni
dietetiche, evitamento pervasivo) che lo rendono particolarmente refrattario e
compromettente. Pertanto, sebbene non sia raro che le persone con emetofobia
presentino una comorbidità intrinseca alla psicopatologia (Price et al., 2012;
Vea l e et al., 2012), tale disturbo può essere clinicamente diagnosticato al fine di
dare priorità ai sintomi di SPOV che mirano a deteriorare il funzionamento degli
individui.
Fig. 1. Flow Chart delle strategie di ricerca e delle procedure di selezione (2000 – 2018)
BIBLIOGRAFIA
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Boschen, M. J. (2007). Reconceptualizing emetophobia: A cognitive–behavioral formulation and research agenda. Journal of anxiety disorders,21(3), 407-419.
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La fobia specifica per il vomito: una
rassegna sistematica internazionale.
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Article
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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.
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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.
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Background: Vomiting is an almost universal phenomenon, but little is known about the aetiology of a specific phobia of vomiting (SPOV). The associations with vomiting during childhood and autobiographical memories may have relevance for our understanding of the development of SPOV and its treatment. Method: Two groups: (a) a group with SPOV (n = 94) and (b) a control group (n = 90) completed a self-report questionnaire assessing their lifetime memories of both their own vomiting and others vomiting. Results: People with SPOV recalled the memories of their own and others vomiting experiences from an earlier age and rated them as significantly more distressing than the control group. There was no difference between the groups in the number of memories of their own vomiting recalled before the age at which vomiting became a problem. However, the SPOV group recalled more memories of others vomiting before the onset of the problem. After the age at which the phobia became a problem they recalled less memories of their own vomiting and more memories of others vomiting than the control group. They recalled significantly more memories of vomiting associated with inter-personal events, health or emotional or unrelated life events. Conclusions: Avoidance and hyper-vigilance for others vomiting after the onset of the phobia may have slightly reduced the risk of vomiting. There is some evidence for associative learning in SPOV with aversive consequences of vomiting and an unrelated life event. It suggests a model of autobiographical memories of vomiting that have lost a time perspective and context, which are being reactivated with cues for vomiting. The limitations of the study are those of memory biases in both groups.
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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.
Article
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.
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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.
Edizione italiana: Manuale diagnostico e statistico dei disturbi mentali. Milano: Raffaello Cortina
  • L M Bogusch
  • M T Moeller
  • W H Brien
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Edizione italiana: Manuale diagnostico e statistico dei disturbi mentali. Milano: Raffaello Cortina, 2014. Bogusch, L. M., Moeller, M. T., & O'Brien, W. H. (2018). Case Study of Acceptance and Commitment Therapy and Functional Analysis for Emetophobia. Clinical Case Studies, 17(2), 77-90.