That sounds like a particularly challenging moment for someone already fearful of vomit! I’d encourage you to provide brief exposure-based therapy (a subtype of cognitive behavioral therapy) to facilitate approach to her feared vomit-related stimuli. The goals of this model are to:

1. Decrease avoidance behaviors that reinforce worry.

2. Increase approach behaviors to build confidence and learn that feared consequences are unlikely.

3. Learn to tolerate unpleasant physiological arousal such as nausea sensations and associated anxiety.

4. Cognitively restructure overestimated probabilities and catastrophic views. 

The active ingredient is guiding exposures related to vomit imagery, videos, stories, and associated physiological sensations. These exercises will assist her in ‘retraining the brain’ that what is feared is actually more tolerable than she believes. The Mastering Your Fears and Phobias: Patient Workbook and Therapist Guide are excellent resources to guide therapy. Here is an excellent illustrative case example as well, and a paper specifically outlining the therapy.

A key component to exposure work is also reducing any avoidant ‘safety’ behaviors or accommodations that have arisen in relation to the phobia. For example, if she frequently asks her daughter how her stomach is feeling, avoids surfaces or people she perceives as contaminated, throws away leftovers pre-emptively, avoids eating when nauseated, or passes responsibilities of sick care to her spouse, you’d encourage her to gradually work towards modifying these avoidant behaviors in favour of approach-based ones.

Other approach-based behaviors may include eating a food (such as yogurt) a few days past the expiration date, cooking meat to the recommended temperature rather than overcooking it, eating at a food truck or buffet, having her spouse and daughter make gagging sounds at random intervals, listening to people describe the last time they threw up, gagging (with a toothbrush or tongue depressor) over a trash can, and riding amusement park rides. Interoceptive (body-based) exposures such as spinning in a chair, wearing a tight scarf in an overheated room, or eating past full could be essential to helping her tolerate the physical sensations she likely avoids. A longer list of sample in-vivo (real-life) exposures can be found here.

In addition to exposure work, reimagining and cognitive processing of the aversive experience she had related to her daughter would be warranted. She could narrate this experience and listen to it repeatedly for the purposes of processing and recognizing the survivable (albeit disgust-eliciting) aspects of the story and gain mastery over the memory. She may also wish to design an imaginal exposure of herself vomiting. In this way, the brain begins to reclassify the fear-inducing stimuli as safe and tolerable. 

Lastly, for some patients with vomit phobia, the shock of the unexpected (such as walking in and seeing the vomit on her daughter) can be a related core fear that may benefit from specific attention. Startle exposures such as playing jump scare games/mazes, watching jump scare video clips, watching thriller movies, setting off loud alarms at random times, playing board games like Perfection or Operation, or having a partner or housemate set off the smoke detector at random times can help patients begin to tolerate the startle sensation.

Slowly, but surely! First, by understanding the rationale for treatment can go a long way. Here is some of the background I share with patients. Vomiting aversions make sense in humans’ evolutionary history because prior to modern advances like refrigeration and canning, foods spoiled readily and could be hazardous. Vomiting was a key part of saving the body from pathogens and when members of a tribe vomited, it sent warnings to others that something their group ate could be dangerous (hence sympathetic vomiting reactions). However, in the era of modern medicine, it’s very unlikely that vomiting is indicative of a life-threatening problem. Further, the act of vomiting itself remains a safe and helpful body response, not something hazardous to do. 

Yet, individuals with specific phobia have been known to hold sentiments such as, “Vomiting is one of the WORST things I can imagine… it’s up there with dying.” The therapeutic task becomes convincing the brain that although vomiting is physically unpleasant, it is tolerable and manageable. Exposure-based therapy reduces the fear associated with vomiting via increased approach-based practice with vomit stimuli, sensations, and situational triggers. For most people, vomiting is a ‘low base rate’ activity, meaning happening rarely, compared to a ‘high base rate’ activity like eating, happening multiple times per day. To convince the brain that vomiting is not dangerous, but in fact safe and tolerable, frequent exposures or practices with the feared stimuli (vomit imagery, fake vomit, spitting food into the toilet, making vomit noises or having loved ones make vomit noises, gagging practice, eating past full) are recommended. This could include doing daily practice guided by a therapist or through a self-guided practice. The webpages www.emetophobiahelp.org or www.emetophobia.net can provide the exposure images to get started. The therapeutic approach is also outlined in detail here here.

The idea is to do daily exposure practice like you would train for a 5k run or as part of physical therapy. In this case, you want to teach your brain that even when it gets anxious from seeing pictures or thinking about vomit, it’s a ‘false alarm’ and your feared outcome (becoming so disgusted I can’t function, passing out, losing control, getting so sick I’d be hospitalized, dying) does not happen. It’s important to identify which of these core fears are most relevant (by asking “What would be so bad about someone vomiting in your presence?”) to help select the best exposures. Over time, the body and brain get more comfortable being uncomfortable. The highest-level practices may involve making some ‘fake vomit’ recipes (powdered oatmeal, cream of mushroom soup, milk, and something darker like pasta sauce or molasses or gravy) and making vomit scenes in the vomit bucket, toilet, sidewalk, or floor. It’s important to practice using paper towels to clean up, just as you would when helping a child. Repeat this practice with more authentic odors by leaving a fake batch out in the sun for a day or two. 

For parents, design an approach-based game plan for making the most of the low-base rate experience of a child vomiting. For example, instead of assigning duties to a spouse or going into full kitchen glove, masked, sanitizing avoidance mode, make a plan for the things you want to be able to do in that moment – ideally: hand the child a bucket and tissues, rub their back or hold their hair and stay by their side long enough to make sure they are ok, then grab paper towels and clean up, start the laundry, wash hands, and return to the child’s side. If a parent is not ready for all of those steps right away, choose the most important and focus on those first with spouse or friend support (if available) for the rest. 

Lastly, imaginal exposures (repeatedly imagining the full story of others vomiting) would likely be useful, as well as potentially practicing with other unexpected stimuli (such as startling when playing jump scare games). Here is an excellent parent-related case example.

Great question! Depending on the severity of the choking and vomit phobia, avoidance behaviors range from mild functional interference such as excessive chewing to major medical complications such as malnutrition necessitating hospitalization or a feeding tube. Fear-driven dietary restrictions are common, with particular avoidance of stringy, dense, or less dissolvable foods (such as melted cheese, bagels, or meats). Avoidance may eventually lead to a diet limited to liquids or pureed foods (soups, smoothies) for some individuals.

Patients may feel unable to swallow pills, which can contribute to medical complications. Please see here for two pill swallowing strategies. Here are some video trainings as well:

https://www.youtube.com/watch?v=Zxqs7flHJQc

https://www.youtube.com/watch?v=37ZRkenMDxE 

When eating, individuals with these phobias may take small bites, manipulate the food carefully, sip water excessively, and check for chunks. Patients may pocket the food on the side or front of the mouth, swallow the smallest bits, and continue chewing isolated chunks. They may even spit out foods that ultimately “feel like they won’t go down.” In some of the most severe cases, patients begin to fear swallowing their own saliva and spit or wipe it away. Patients with choking or swallowing phobias may engage in rumination, or the retrieval (regurgitation) of food that has been recently swallowed. Ruminated food is chewed and re-swallowed or spat out. In the case of phobias, rumination is often voluntary, though involuntary rumination is an observed phenomenon as well. 

The cumulative time taken eating slowly and carefully and engaging in this host of avoidance behaviors often becomes excessive, impairing, and frustrating. Difficulty coping with the anxiety of eating has led some to alcohol consumption or taking benzodiazepines (such as Xanax) with meals. These strategies prevent patients from learning that the foods they are attempting to swallow or keep down are quite safe to consume. In other words, these substances prevent disconfirmation of their feared outcomes. Patients are encouraged to wean off of substances (with medical guidance if indicated) over the course of treatment. 

Situational avoidance is common as well. Patients with choking/swallowing fears may avoid eating alone so that someone can assist them if they begin to choke or conversely insist on eating alone to fully focus on swallowing carefully. Patients with vomit fears may avoid eating in public settings to reduce the chance they will vomit in public, avoid eating when they already nauseated (even when the source is anxiety), or avoid eating before being in a car. They may also avoid using their toothbrush too far back on their tongues (eliciting gagging). 

Lastly, patients may engage in reassurance-seeking behaviors, such as speaking/coughing/taking deep breaths to ensure that the airway isn’t blocked or double swallowing. Patients may also verbally seek reassurance from others (“It’s safe to try and swallow this, right?”) or mentally reassure themselves (“I’m fine, I’m not going to throw up.”). While in the short term, these reassurances may help the patient consume food, in the long run, they reinforce the fear and prevent the patients from learning that they would likely be safe without the safety behaviors. 

To assess avoidance behaviors in patients, check out the Specific Phobia of Vomiting Inventory (SPOVI) and the Emetophobia Questionnaire (EmetQ-13) at https://www.veale.co.uk/scales/ as well as the Swallowing Anxiety Scale (SAS) at https://link.springer.com/article/10.1007/s40519-017-0367-z.

While the research remains limited, a percentage of patients (50 to 75 per cent in some studies) report having experienced or witnessed an aversive/traumatic encounter with vomiting or choking. The remaining patients cannot pinpoint a specific moment that triggered the onset of their fears. In either instance, the onset of phobias typically starts with a pattern of avoidance that becomes highly reinforced and more interfering over time.

For example, a patient who experienced a vomiting episode late at night may shape her evening mealtime schedule, food selection, and antacid dosing around trying to keep her stomach calm through the night. Each successful night without vomiting reinforces the idea that she’s keeping herself safe and builds fears that deviation from the plan could result in vomiting. In another example, a patient who develops a swallowing phobia ‘out of the blue’ may feel increasingly stressed by foods and associated swallowing sensations and slowly begin excluding denser or difficult to swallow foods to save time and reduce distress. Over time, the avoidance leads to a limited diet, excessive chewing patterns, and reassurance-seeking behaviors. As avoidance grows, patients limit the opportunity to disconfirm their fears and cognitive errors such as overestimated probabilities and catastrophic views of the feared outcome overtake logic.

Many patients have a predisposition for anxiety based on family history, which presents genetic and environmental risk for shaping the individual’s development of the phobia. Some patients report having a family member that repeatedly cautioned them to be careful while eating so they don’t choke or vomit.

Though data on this is lacking, clinical experience suggests that some patients have mild abnormalities in their swallowing anatomy or general increased visceral sensitivity and hypervigilance that lead people to experience ‘stuck’ or ‘odd’ sensations that increase fear. Lesions, thyroid nodules, enflamed lymph nodes, or recent inflammation in the throat (such as from illness or a choking scare), can make swallowing feel different or harder and therefore produce anxiety. Similarly, abnormal motility in the upper digestive tract can create the sensation of having difficulty swallowing. For more information visit https://www.youtube.com/watch?v=GR-Q_MgUMXE. 

Patients are encouraged to have a ‘rule out’ appointment with a medical doctor to discuss whether it is advised to follow an unrestricted diet and engage in a hierarchical food exposure plan. Even in instances when a medical doctor finds no abnormalities and encourages normal engagement with foods, patients often report feeling that swallowing continues to feel difficult or off. Patients with choking/swallowing phobias are more likely to be viscerally sensitive and hypervigilant to sensations in their throat. Swallowing has both voluntary and involuntary components, so increased attention or hypervigilance likely contributes to it feeling wrong or different. Patients who begin to fear swallowing may note that they feel like they have to force swallows or are swallowing differently than usual, which only serves to increase the fear. 

Therapeutically, patients are encouraged to note and accept the sensation (“this may continue to feel off”) and keep moving up their behavioral exposure hierarchy. Patients can be taught about swallowing. Patients who are hyper focused on swallowing safely may be encouraged to focus their attention elsewhere. Conversely, others may find focusing on their swallowing particularly scary, in which case ‘pay attention to swallowing’ may be added as a specific exposure on the hierarchy.

For youth, interventions parallel the adult interventions described above. The evidence-supported CBT approach would include both behavioral exposures and cognitive processing of the disconfirmation of feared outcomes provided by the exposures. For vomiting phobias, this would include exposures with aversive images, videos, sensations, and food-based practice in both low stress and high stress contexts (such as when already anxious about vomiting). For swallowing phobias, gradual food approach and reduction of safety behaviors would be encouraged. 

There are a few modifications of protocols that come to mind when treating youth. Special attention should be paid to the role of family accommodation in youth cases. Therapists can assess family accommodation with the freely available Family Accommodation Scale. Then, sessions can incorporate gradual reductions in accommodation that pair with the introduction of exposures. For example, if a child continually asks their parent if a particular food is “okay” to consume, parents would practice introducing supportive but non-reassuring statement such as, “Maybe, let’s try” or “I can’t give you the answer the anxiety is looking for, but you’re brave, give it a go.”  

Additionally, unlike treatment-seeking adults who may be sufficiently motivated to work on their phobia, youth may struggle to engage with exposure tasks. A consistent, reinforcing reward system may be necessary to get exposure work off the ground. A system that works well for families is rewarding quick engagement in the exposure task rather than delaying or negotiating (worth one point) and completion of the exposure task to the specified end (another point). Adherence to both components may earn a bonus point (three points in total). If a component is missed, say a quick, “You’ll get it next time!” and move onto the next thing planned for the day. 

Rewards can range from special time with a parent, screen time, small toys or collectable cards, or being the ‘boss for the day’ (of the car radio station, movie night selection, dinner choice, and so on). Rewards may be given at the time of exposure completion or be deposited in a token economy system. Exposure practice ideally should occur daily and become integrated in the schedule. The more regular or mundane a family can make the practice, the more a child learns that the expectation that they do exposure work doesn’t change, they can tolerate it, and they benefit from the daily disconfirmation of feared outcomes.

Great question and glad to hear the CBT is reducing avoidance! Yes, when she’s ready to move to the next step, I’d help her address nausea/vomiting directly. For many of the approach-based exposures you’ve had her doing so far, my guess is that she’s had an array of experiences that disconfirm her fears (such as, she doesn’t vomit). This is wonderful and provides some newfound freedom regarding things she can approach! However, patients with anxiety disorders have strong ‘what if’ worries, so it’s best to confront these as well. 

Exposure work in this regard can be a win-win in that most of the time, exposures don’t produce the feared outcome (a disconfirmation win) and when we purposefully produce a negative outcome (such as become nauseated on purpose or gag to the point of vomiting) patients realize that while aversive, this is more tolerable/survivable than their anxiety made it seem (an “I did it and it wasn’t that bad” win). This is similar to the idea that in social anxiety CBT, we encourage people to not only drop their safety behaviors and engage in normative social interactions but also add ‘social mishap’ exposures in which they are purposefully doing something silly, embarrassing, or socially off. This “even if my feared outcome happens, I can tolerate it” lesson can be particularly powerful.

To accomplish these exposures and induce nausea or approach the risk of vomiting directly, encourage the patient to engage in interoceptive (body-based) exposures that mimic the sensations she fears most. Examples include spinning around while standing or in a chair, eating past full, drinking an entire carbonated beverage quickly, reading in the back seat of a car, gagging with a toothbrush morning and night, or spitting chunky soup or chili into a toilet. The advanced version of these exposures may include coupling several together (such as eating past full and then riding in the back seat). 

Note that in the past, providers may have used ipecac to induce vomiting for the purposes of a planned exposure. However, ipecac has been shown to be quite toxic and this intervention is no longer supported. Therapists are thus encouraged to make the top of the exposure hierarchy comprised of whatever items the patient believes run the risk of inducing vomiting. If vomiting occurs, they are able to process how safe and tolerable it was in reality. If no vomiting occurs, they learn that for them, vomiting isn’t going to happen at the drop of a hat and they are able to functionally approach many things that had been previously avoided.

The fight or flight system that gets activated during moments of panic or high anxiety produces a cascade of hormones designed to prepare our bodies for an intense battle for our safety. The sympathetic nervous system causes muscles to tighten and potentially generate the lump-in-the-throat feeling or globus sensation. Further, individuals experiencing globus have been shown to be more hypervigilant and aware of visceral sensations, either within the context of swallowing or not. 

Globus is considered a benign condition (not leading to choking), though medical assessment to rule out other underlying conditions is encouraged (Lee and Kim, 2012). A number of physical and psychological explanations for globus have been posited, but empirical work has not yet confirmed the causes of the stuck sensation. Cognitive behavioral therapy is recommended to assist patients reduce hypervigilance of stuck sensations, approach avoided circumstances, and return to full functioning. Other interventions (antacids, speech therapy, antidepressants) may be less relevant to the anxiety-associated type of globus sensation.

Assuming the child is plugging away at exposure-based CBT, the parents’ best role is that of cheerleader and daily exposure taskmaster. Understandably, parents get roped into various types of accommodation over time (such as providing reassurance, preparing specific foods, cleaning, permitting school absences, reducing expectations when nausea is present and so on). It’s important to help parents understand that while accommodation is 100 per cent the natural thing for any parent to do, it also needs to change to help a child with this particular disorder. 

Parents who learn to do this well take on an “I love you too much to give the accommodation” attitude and frame their decisions to reduce/remove accommodation as providing a long-term benefit (aka symptom relief). They help their child ride out the short-term distress by being present and supportive of the child and avoid specifically reassuring the anxiety away. For example, a child that wants the table sanitized before eating may hear, “I understand why you want that, but remember we talked about not doing it anymore to help the vomit worries get better. I know it’s disappointing and scary, but I know you’re brave and can handle it. Let’s get the table set and we’ll get through it.” 

Parents really need to be sold on the rationale in the first few sessions, so I have them attend those. Analogies such as anxiety being like a bully demanding lunch money can help parents understand that continuing to submit to the bully is on the one hand natural, but also will make it continue to come back for more and more. Additionally, therapists can use this analogy to help parents anticipate that when lunch money is denied, the bully will likely demand forcefully, become angry, and test whether it will get any for a number of days, but eventually go bother someone else. This can help parents anticipate a surge in accommodation requests, followed by their child adjusting to not having the accommodation. 

In addition to cheering the child on through the process, parents are responsible for keeping children accountable to the daily exposure plan. When I’ve had cases flop, more times than not it was because a busy parent was inconsistent about enforcing or rewarding regular exposure work. The more consistent and mundane a family can make the practice, the more a child learns that the expectation that they do exposure work doesn’t change, they can tolerate it, and they benefit from the daily disconfirmation of feared outcomes.

In addition to the exposure-based protocols described above, I’d pair with a physician and nutritionist to make sure adequate calorie consumption can occur. If she’s in an at-risk range, getting the calories in becomes the priority, essentially by whatever means necessary in the beginning. This may mean calorie boosting with supplements, smoothies/milkshakes, or nutritional beverages, adding calories to currently accepted foods (such as avocado, butter, whole milk, ice cream, oils), or increasing the portion size or frequency of her currently accepted foods. I’d encourage you to break down the meal plan for the day and troubleshoot what to do when her anxiety about vomiting is high and how she can push back against the avoidance urges and approach something to eat (even if it’s liquids or what I call ‘happy carbs’ like toast or crackers). You’d focus on helping her tolerate this augmentation for the first few weeks of treatment until the nutritionist or medical team approves the introduction of higher-level exposure work. If she has panic symptoms during this process, you can do supplemental panic work. I recommend Mastering Your Anxiety and Panic by Michelle Craske and David Barlow.

Once you’re able to get rolling a bit, exposures may initially be divided into two categories – difficult exposures conducted when the patient is at a baseline low anxiety level and easier exposures conducted when the patient is already very activated (to ensure adequate calorie consumption). For example, she may aim to eat past full as an exposure on a ‘good day’ and aim to approximate the amount set by the nutritionist (when she historically would eat nothing or very little) on a ‘bad day’. Over time, the hope would be to move up the hierarchy and conduct exposures regardless of the status of her anxiety (such as eating a non-preferred food on both good and bad days). Often, emetophobic patients will avoid eating when anxious or nauseated, so the first step of adding in ‘easier’ exposure foods at the beginning is intended to provide the first experiences of disconfirmation (I was able to eat that and I didn’t vomit). 

When it comes to specific non-preferred items to add to the hierarchy, she may overly rely on telling you she just doesn’t like a food or she has a nausea-inducing association with it. Luckily, humans can habituate to anything that is objectively safe, so she will eventually get used to consuming foods she doesn’t love and likely get disconfirmation of nausea/vomiting fears. She’ll likely need repeated practice with some of these foods to disconfirm the idea that it ‘doesn’t agree’ with her. Very few foods will probably have that impact once her food consumption is regular and back on track. Plus, anxiety itself can generate nausea, so she’ll need to engage with regular exposure work over a period of time to see what shakes out as an intolerable food. Lastly, low calorie consumption can make battling anxiety more difficult, so a patient would ideally be weight restored by the time the bulk of exposure therapy is conducted.

Comorbid conditions include panic disorder, major depressive disorder, avoidant-restrictive food intake disorder (ARFID), anorexia nervosa, obsessive-compulsive disorder (OCD), social anxiety disorder, generalized anxiety disorder, illness anxiety disorder, and other specific phobias. Treating the phobia effectively would be expected to alleviate a great deal of comorbid depression and could be re-assessed as exposure therapy concludes. Among patients with ARFID, nine to 13 per cent had a history of vomiting or choking or an aversive/traumatic experience (though not an identified phobia) that may have set the course for avoidant eating patterns warranting the ARFID diagnosis. 

In patients with OCD, choking or swallowing fears and compulsions often have an illogical component (though the diagnosis likely remains OCD rather than a comorbid specific phobia diagnosis). Individuals with OCD-related choking/vomiting obsessions may fear impulsively doing something unsafe with their food such as taking large bites and dangerously rushing their swallowing, putting something inedible in their mouth and swallowing it, or accidently ingesting something harmful such as glass or plastic chunks. Avoidance behaviors such as ripping off bites to eat rather than biting the food directly, keeping small inedible objects out of reach, and checking food repeatedly may occur. Some cases become severely underweight and experience a number of functional impairments (see a case example here). 

Patients with OCD may also generically fear choking or swallowing (and present looking very similar to a specific phobia case), but do repetitive rituals or excessive behaviors not seen in classic specific phobia cases. Asking about a family history of OCD, engagement in excessive reassurance-seeking or repetitive/neutralizing behaviors, and a lack of response to phobia-based CBT can provide clues that exposure and response prevention (ERP) therapy for OCD may be indicated. For more information go here.

Though not a comorbidity per say, patients should be screened for anorexia nervosa when presenting to clinics for emetophobia or choking phobia treatment and vice versa, anorexia nervosa patients should be asked about fears of choking/vomiting. Because individuals with eating-based fears can readily become underweight, patients presenting in primary care offices as ‘failure to thrive’ or underweight cases should be asked about choking/vomiting fears as well. Then, referrals to exposure-based CBT-providers are important.