Kylie had always been an anxious child. She didn’t like to be separated from her mother, Sidney. As a three-year-old, she developed a sort of vocal tic, a persistent cough, after a bout with walking pneumonia. Soon there were other compulsive behaviors, like asking repetitive questions.

In pre-K, Kylie threw up after eating canned peaches, and from then on became increasingly fearful of vomiting or being around vomit. “It was very insidious,” says Sidney, who has a master’s degree in special education. “I think her mind was working and taking these little baby steps down this path of fear almost.”

One night, Kylie told her mother she wasn’t going to wear her pajama top to bed. Soon, she was refusing to wear any pajamas, and she slept on top of the covers. Then she dragged a comforter into her closet and slept on that. Next came the pillow, which she used to prop herself up into a sitting position while she slept. She was five years old.

Kylie’s parents tried reassuring her. They tried using rewards. If they attempted to march her over to the bed, Kylie panicked. “Kicking, screaming, punching,” says Sidney. “It was like, imagine if you’re going to be murdered imminently and you knew that.”

Kylie’s problem is called emetophobia, or the severe fear of vomiting or seeing others vomit, and it’s surprisingly common among both children and adults.

How the fear develops

Of the 1,500 or so children he has treated in his career, Dr. Jerry Bubrick, a clinical psychologist at the Child Mind Institute who specializes in anxiety, estimates that 10 to 20% have presented with emetophobic symptoms. Like Kylie, many of his patients already have an “anxious temperament” before they start showing signs of the disorder, which might be triggered by seeing other kids at school or on the bus vomit, or vomiting themselves.

“They start to associate cues in the environment that they remember with vomiting,” he says, “and then start to become fearful with those cues.” Bit by bit, they begin avoiding places and things they associate with throwing up, even refusing to say or write the word “vomit.” They become strict in their dietary habits, eschewing anything they’re not familiar with or fear could make them sick, compulsively checking expiration dates on food items. In some cases, malnutrition becomes an issue.

The fear escalates

One of Dr. Bubrick’s recent patients, for instance, a young girl already living with anxiety, contracted food poisoning on Thanksgiving. Over the following days and weeks, she grew increasingly fearful of anything associated with Thanksgiving food—avoiding not only the leftovers, but any food linked to the holiday. Soon she was refusing to wear the clothes she’d had on the day she got sick and wouldn’t even walk into the rooms she’d been in immediately prior to and after vomiting.

Some children, says Dr. Bubrick, can’t articulate their fear, leaving parents to guess at, and, unfortunately, underestimate the phobia’s grip on their child. “Normally, like all phobias,” says Dr. Bubrick, “it starts out kind of small, and it builds, and builds and builds. But when it’s kind of small, parents are like, ‘Well, it’s not that big of a deal. She’ll grow out of it. She’ll come around.’ But then, over time, it just gets to the point where parents are like, ‘This is crazy. We can’t live like this anymore.'”

Before the breaking point, however, parents do what comes instinctively—they comfort and reassure their children. Doing so only prolongs the problem. Dr. Bubrick likens it to scratching a bug bite. “When you get bitten by a mosquito,” he says, “it itches, and it’ll make you feel better the moment you’ll scratch. But as soon as you stop scratching, the itching gets worse. The very thing you’re doing in the moment to make it better, in the long term makes it worse.” When children avoid things that trigger their fears, or seek reassurance to calm their anxiety, it only strengthens the phobia.

Related: What to Do (and Not Do) When Children Are Anxious

Fears are often dismissed

For seven or eight months, every night in Sidney’s home ended the same way. Kylie was exhausted. Sidney and her husband were exhausted. If someone had vomited at school, Kylie would manage to hold it together until she got home, and then, says Sidney, she’d hit the house “like a tornado,” throwing away clothes that could have potentially touched the vomit. Doctors said the little girl was just being defiant. “It was a whole gamut,” says Sidney. “She was being controlling. It’s a sibling rivalry because my son had just been born. She’s attention-seeking. She’s being manipulative.”

Related: How Anxiety Leads to Disruptive Behavior

This response is not uncommon, according to Dr. Bubrick. Parents and pediatricians unfamiliar with the phobia tend to think of it as a phase that will go away, and take a wait-and-see approach. But there’s another reason children go untreated, carrying their fears into adulthood: shame. Anna S. Christie is a counselor based in British Columbia, who began suffering from emetophobia as a young child. Her fears were dismissed by the adults around her, so while she still experienced severe symptoms, including terror at the thought of going to school or on field trips, she learned to keep the root cause to herself, developing “incredible shame.”

Related: How to Avoid Passing Anxiety on to Your Kids

“Even with my own mom, I would just be told it’s ridiculous, so very quickly I stopped telling anybody about it,” says Christie, who now mentors emetophobic children and adults online. “My mom kind of knew, I guess she always knew, but I would not even say it to her. ” It wasn’t until Christie was in her mid-forties that she was able to find enough information about her phobia online to take to a therapist and begin working through it.

The connection with OCD

About a year after Kylie’s bedtime ritual started, Kylie’s anxiety escalated. “I was rocking the baby in the rocking chair,” says Sidney, “and she came up and she put her arm around my neck, and she looked at me, and she said, ‘Mommy, I want to hug you but I’m not going to. I think I might strangle you.’ ”

Kylie wouldn’t set the table for fear she’d take a knife and cut her own finger off. She wouldn’t play with her siblings for fear she’d smother them. She was diagnosed with severe obsessive-compulsive disorder.

While emetophobia is technically a specific phobia, Dr. Bubrick says it’s more closely associated with OCD than with a phobia like a fear of spiders, which is more discreet. In fact he estimates about 30 to 50 percent of the kids he’s treated with a fear of vomiting also exhibit OCD symptoms.

“There’s a lot of different presentations of OCD,” explains Dr. Bubrick. “Some kids are afraid of harming other kids or their family members, or they’re afraid of germs and bad luck, and all kinds of things. Over the years, I’ve seen a lot of kids who are afraid of vomiting.”

Treatment with exposure therapy

Kylie’s doctors began addressing her OCD and emetophobia with a kind of behavior therapy called exposure and response prevention. The clinician works with the child to create a hierarchy, rating the things that trigger her anxiety on a scale of one to ten. Then, starting with the lowest rung, the child is exposed to the things she’s been avoiding, often in tiny, incremental steps. For an emetophobe, that could mean starting by writing the word vomit, then progressing to talking about it, drawing it, seeing cartoons or photos of it, possibly even being around a facsimile of it. They experience anxiety, but they also learn that the anxiety fades.

“When we expose patients systematically to things that they’re afraid of, without allowing them to push it away, their anxiety will go up and up and up, peak, and it’ll come down by itself,” says Dr. Bubrick. After the 10th or 50th repetition of an action—say, eating a potato chip that’s past its expiration date—patients experience a “cognitive shift,” in which they realize the thing they feared wasn’t as bad as they thought it would be. “If they’re constantly pushing the anxiety away,” says Dr. Bubrick, “they’ll never have that experience.”

Kylie continued therapy for a couple years, and remains on medication. Today, she still struggles with her fear of vomiting, but she’s not only sleeping in her own bed, but is now venturing out into the world with confidence. Last year she attended an overnight camp for two weeks, and she’s since upped the ante. “It’s just like a miracle,” says Sidney, “she will be at camp for four weeks, by herself, and is able to sleep in a bunk like everyone else. It’s something I never, ever, ever thought would happen.”

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