Hypnosis for the Treatment of Emetophobia

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By Ran D. Anbar, MD and Amy Chambers, FNP

Emetophobia can be defined as an extreme fear of throwing up, seeing someone else vomiting, or encountering vomit (Faye et al., 2013). Emetophobia can cause patients a lot of problems participating in daily activities; they might panic if they don’t feel well or avoid situations in which they might be exposed to someone who is sick. Emetophobia is also frequently associated with the development of recurrent nausea or stomachaches.

Emetophobia has been reported to affect 0.2% – 7% of the general population (van Hout & Bouman, 2012) and is one of the most common phobias for which patients seek treatment. It is often associated with obsessive-compulsive disorder (OCD). Children are more often affected by this phobia, which on average begins around the age of 9 (Lipsitz et al., 2001).

Emetophobia has been treated successfully with Exposure Response Prevention (ERP), which is considered the gold standard for treatment of OCD and anxiety (Gillihan et al., 2012). ERP involves exposing patients to triggers of their phobia with increasing intensity until they learn to tolerate their fear.

For instance, for treatment of emetophobia patients might first be encouraged to remain calm while they are repeatedly brought into a room while someone next door is gagging. Once they tolerate this condition, they can be brought into a room in which someone in the same room states they feel nauseous. An even more intense exposure can be when patients are asked to taste substances that are reminiscent of emesis. ERP has been shown to reduce fear and associated nausea in patients with emetophobia (Philips, 1985).

However, patients can be resistant to participation in ERP because the exposure triggers their fear and is very uncomfortable. Further, following ERP they are instructed to continue to expose themselves to triggers, and often avoid doing so because of residual associated discomfort.

As an alternative therapy, we described in this blog how two types of interactions with the subconscious have been very effective in treatment of emetophobia with children and adolescents.

Our patients are first introduced to the concept of the subconscious after they learn to calm themselves through the use of hypnosis. Hypnosis is defined as a way of “using your imagination to help yourself” and the subconscious is defined as “the part of your mind of which you are usually unaware.” For younger children we use the label “inner advisor” instead of “subconscious.”

Interactions with the subconscious can be accomplished in many ways, such as having the subconscious answer questions through finger motion, talking with the patient’s voice, or writing on an imaginary whiteboard.

Internal ERP

Internal ERP (iERP) was developed because patients often avoid situations in which they might be exposed to their triggers, including after ERP therapy. With iERP once the subconscious indicates it is willing to help a patient, it is charged with showing the patient imagery of triggers at random times every day. As patients do not know when the imagery might occur, they can no longer avoid it. The patients’ job is to tolerate the imagery. Like with ERP, the subconscious is instructed to gradually increase the intensity of the imagery over a period of several weeks.

We have seen patients weekly during this time and check in with the subconscious regarding the frequency and intensity of the iERP. The patients’ subconscious have reported use of triggering imagery from 2-10 times daily, including during dreams. The patients often report that they are not always aware of the imagery, and sometimes feel anxiety without a clear cause. The subconscious is queried as to whether the patient is ready for an increase in image intensity, and if so, encouraged to increase it.

Patients’ emetophobia has resolved within 4-9 weeks in ten of our twelve patients (age range 7 – 24 years) who have used iERP.

Red Light/Green Light System

After securing the subconscious’ agreement to help, the patients are familiarized with the technique of asking their subconscious to show them red and green lights. For instance, they can be prompted to ask their subconscious to show them a green light “in their mind’s eye.” It is suggested that this may look like a traffic light or any other type of green light the subconscious selects. The patient is asked to acknowledge when the subconscious has shown them this and to describe it verbally. For example, they might report that, “It looks like a traffic light” or “It’s just a green glowy light.” Then, the patient is instructed to ask their subconscious to similarly show them a red light, acknowledge when this has happened, and describe it verbally.

Thereafter, the patients are instructed to ask their subconscious about a typical worry regarding their emetophobia, such as, “Will my stomach be ok today?” or “Will I feel good at school today?” Further, they are instructed to query their subconscious at any time they don’t feel well, develop stomachaches, or are worried about throwing up. The subconscious is supposed to respond by showing them either a red or green light.

A green light indicates that the patients are fine and are “good to go.” The patients are told at this point that they can let the worry go because they no longer need it. Most patients accept this suggestion readily, and many times even with an expressed sense of relief. When a red light appears, patients are instructed to ask their subconscious what they should do to calm their stomach, and to follow this advice. Then, they are supposed to ask again, “Will my stomach now be okay?” This process is repeated until the subconscious shows them a green light.

All ten of our patients (age range 8-12 years) who have used the red light/green light system have reported that within 4-6 weeks their emetophobia has become manageable or has resolved.