Fear of Vomiting and Exposure Therapy

The fear of vomiting is a very, very common one in the world of anxiety disorders. Scott Stossel, in his bestseller, My Age of Anxiety, makes it clear that it’s not just a matter of feeling queasy at the thought of vomiting (who doesn’t feel that way?) but an anxiety so toxic you find yourself arranging your life meticulously, painstakingly to avoid it. The challenge is that this phobia can ambush you practically anywhere—if you think about it, where could you not, hypothetically, vomit?

So it’s not surprising that one of the most dramatic parts of the book (and, in shortened form, the Atlantic excerpt) is Stossel’s account of his misadventure with what he calls exposure therapy, designed to rid him of his vomiting phobia. It turns into a disaster when the ipecac he takes to make him vomit—in order to diminish the massive anxiety attached to it—fails to make him vomit. Instead, it just makes him violently ill, curled on the floor of a clinic bathroom for hours on end, and more anxious than before. (He notes, by way of humor, that the fiasco did succeed in making his therapist vomit.)

I mention this because the scene is so vividly memorable that I worry that it will give exposure therapy a bad name. And it’s so unlike the kind of exposure therapy we’re familiar with at the Child Mind Institute that I asked Dr. Jerry Bubrick, an expert in treating anxiety, what might have gone wrong in Stossel’s case.

Dr. Bubrick notes that most exposure therapy works by introducing the source of the fear in tiny increments, so that the patient learns to tolerate them one at a time, and doesn’t move from one to the next until he is so over being anxious at each step that he is actually bored. The patient and doctor create a hierarchy of fears that run from, say, writing the word vomit to watching a video of someone vomiting, and the patient becomes habituated to each before moving on to actually doing the things that he associates with vomiting—let alone vomiting.

Dr. Bubrick showed me a piece of paper covered with the word vomit that was the work of an 8-year-old he happens to be treating right now who shares Stossel’s phobia. This little girl was so anxious at the outset that just hearing the word vomit made her curl into a ball and check out of the session, so Dr. Bubrick said he backed up and started with something easier, having her write the word vomit, first in tiny letters and then progressively bigger—and finally in purple.

There are clinicians, Dr. Bubrick said, who believe in extreme exposures—”going to the top of the hierarchy as quickly as possible.” But that could only work, he said, if the patient really buys into the model, has confidence that he will be able to handle the anxiety and habituate to it. That confidence, along with trust in the clinician, generally comes from those earlier baby steps, and it’s clear from Stossel’s account that he didn’t have it.

It takes time and patience. “You can’t expect someone to face his worst possible fear and get bored quickly,” he notes. “But when I expose patients to things much lower in intensity, that cause much less fear, and they understand the mechanics of exposure, time and time again, and it’s working more and more, they’ll be much more motivated to face their biggest baddest fear and it will be much more effective when we do it.”

Dr. Bubrick notes that he got a picture the other day from the mom of a 10-year-old boy who graduated last fall from treatment for a vomiting phobia. It was a picture of a pumpkin her son had carved for Halloween—and the pumpkin was vomiting.

Dr. Bubrick, by the way, would love to treat Scott Stossel.