Emetophobia: A fear of vomiting
An 8-year-old girl, studying in second grade was brought by parents with complaints of fear of vomiting and feeling nauseated since about seven and half months. Around 20 days before the starting of symptoms, child had episode of acute and severe abdominal pain, high grade fever with 3 bouts of vomiting with nausea for a day. She was diagnosed as having acute appendicitis by a surgeon and was operated subsequently. Within around 10 days after operation, patient started having fear of similar episode of vomiting with repeated remembrance of the episode. She complained of feeling nauseated with excessive salivation and gastric regurgitation. The treating doctor did not find anything significant and was treated symptomatically. Parents were reassured about the symptoms. She started attending her classes but gradually her complaints increased. She had constant thoughts of feeling nauseated. She started eating less, avoiding outside food which she used to ask for previously. She would worry about the pungent smell of vomitus in toilet and ask mother to clean it frequently. The fear increased slowly to the extent that, she started avoiding playing with other children in a fear that they will avoid her and tease her if she vomited in front of them. She avoided school for the same reason and thought that teachers will have bad impression about her if she vomits in the classroom. Meanwhile, parents asked their close relatives to console her. But symptoms went on increasing and she started refusing to use a lift, travel in bus, going to park, market places, etc., Fear became generalized and patient started worrying that her parent may suffer vomiting, she would request parents not to go outside, not to travel in bus or use lifts. Her father was working in a different city and job required frequent traveling. She had persistent fear that he may suffer vomiting as he eats outside food and there is no one to take care of him. She would call him repeatedly on phone and ask to change his job. She also developed reduced and non-refreshing sleep with constant thoughts/worries about vomiting at night with complaints of nausea and regurgitation after having her dinner. History of occasional nocturnal enuresis was also present during this period.\nShe was referred for a psychiatric consultation. She refused separate interview of parents because of the fear that they will hide the illness from her. She elaborated all the complaints and said “I feel nauseated even when I hear a word ‘vomitus’ or ‘vomiting’ or if I see anybody vomiting”. She elaborated the incidence when she vomited after witnessing the same in the neighborhood. Besides this, there was no history of depressive or obsessive-compulsive features or eating disorder and no symptoms suggestive of other phobias. Past history was not significant. There was significant family history and both of her parents are suffering from anxiety disorder and taking regular treatment from a psychiatrist. Birth and developmental history did not reveal any significant abnormality. She was good in academics.\nOn mental status examination, patient described her mood as anxious with appropriate affect. In thought, there was preoccupation about the worries of having nausea and vomiting along with number of questions e.g., whether I will get better; Do I have some severe illness; Will your medicines have side effect of vomiting, etc., She was diagnosed as a case of Specific Phobia of Vomiting i.e., Emetophobia.\nAs it was very difficult to involve the child in counseling or psychotherapy because of severe anxiety, she was prescribed tablet Clobazam 5 mg in divided doses and Cap Fluoxetine 10 mg. She was admitted to a child unit to reassure her as she was not willing to take medicines due to fear of side effects. After a week, she and her parents perceived mild improvement in anxiety and she was somewhat comfortable. On further follow-up, child was taught relaxation and started on Graded Exposure therapy along with the medications. She was exposed to the materials or activities related to vomiting. First, she was asked to read hand written article which contained the word ‘vomitus/vomiting’ (multiple times) as many times as possible. After about a week, she was asked to witness the action of vomiting by parents which they were pretending, followed by behavior as if vomiting has caused no trouble and anyone can suffer it for a short duration. After around 15 days, she was advised to attend school with a facility to go to rest room whenever she has thoughts of vomiting followed by feeling of nausea. She used the rest room only for initial 2 days after which she was as regular to the classes as before the start of illness. She was asked to play with other children only for 15 minutes to begin with. This time was increased slowly from 15 minutes to 1 hour. When she didn’t have even a single vomiting during this period, she started accepting the fact that it was an irrational fear and that she can achieve a mastery over it. Slowly, she was exposed to the activities that can induce vomiting like smelling the toilet, spinning around, etc., She had nausea and she hesitated to do it initially, but with intermittent counseling and relaxation and frequently doing above activities, she could face the feeling of nausea with less fear than before. In view of severity of symptoms and family history of anxiety disorders in parents, patient was advised to continue medications.