Abstract
Emetophobia is an understudied specific phobia, especially during the developmental stage of adolescence. Adult and child literatures suggest that a combined approach of psychopharmacological and cognitive-behavioral interventions may be an efficacious treatment for emetophobia. Despite evidence supporting the success of this therapeutic approach, research assessing treatment outcomes of adolescent populations with the disorder remains limited. The current study presents a case study of the successful use of combined treatment for emetophobia in an adolescent female. Therapy included psychoeducation, cognitive restructuring, and exposure therapy in tandem with Sertraline 50 mg. Upon termination of therapeutic services, symptoms of emetophobia were significantly reduced, panic attacks had remitted, and the continued use of psychotropic medication was no longer indicated. Findings in the present case study suggest that cognitive-behavioral therapy (CBT) including exposure-based therapy effectively reduced emetophobia symptoms and panic attacks for the patient. The implications for these findings in treating adolescents with emetophobia are discussed.
Keywords
1 Theoretical and Research Basis for Treatment
Emetophobia, the fear of vomiting or seeing others vomit, is a specific phobia and is among the least understood anxiety disorders (Boschen, 2007; Graziano, Callueng, & Geffken, 2010; van Hout & Bouman, 2012). Most studies on emetophobia have focused on adult populations (Hunter & Antony, 2009), and releated research indicates emetophobia is more common among females than males (6%-7% and 2%-3%, respectively; Hunter & Antony, 2009; Philips, 1985; van Hout & Bouman, 2012). Despite much of the research concerning emetophobia focusing on adult populations, adolescence is a pivotal time for the development of emetophobia, with research indicating initial symptoms are typically observed surrounding the onset of puberty (Lipsitz, Fyer, Paterniti, & Klein, 2001) or during adolescence (van Hout & Bouman, 2012). Despite these findings, little is known about the development and treatment of emetophobia in adolescent populations.
Emetophobia is considerably more difficult to treat than other specific phobias due to high dropout rates and strong and often negative client responses to being exposed to feared stimuli, particularly in relation to the exposure component of treatment (Kobori, 2011). As with many anxiety disorders, emetophobia is often treated with exposure-based therapies, cognitive-behavioral therapies (CBTs), medication, or a combination of these approaches (Hunter & Antony, 2009; Philips, 1985). One reason using CBT in conjunction with exposure therapy may be beneficial for such cases is that CBT allows for examination of cognitions and inclusion of cognitive restructuring techniques in treatment.
Although research indicates CBT and exposure therapy are effective in the treatment of emetophobia for children (Moran & O’Brien, 2005; Williams, Field, Riegel, & Paul, 2011) and women (Hunter & Antony, 2009; Maack, Deacon, & Zhao, 2013), no studies have examined the use of CBT with exposure-based therapy for an adolescent client with emetophobia. To date, two studies have examined the use of exposure therapy with female children who presented with symptoms of emetophobia (Moran & O’Brien, 2005; Williams et al., 2011). In one study, an 11-year-old responded favorably to exposure therapy with visual imagery (Moran & O’Brien, 2005), and in a considerably more extreme case, an 8-year-old with emetophobia and food refusal was successfully treated through hospitalization and a feeding program in addition to exposure therapy (Williams et al., 2011).
There is some preliminary evidence for the inclusion of psychotropic medication in conjunction with CBT for cases of emetophobia. In one case, Graziano et al. (2010) observed positive treatment gains for an 11-year-old male who was treated with cognitive-behavior therapy in tandem with Zoloft. Another case study demonstrated that a 30-year old female presenting with depression and emetophobia evidenced clinically significant symptom reduction from taking serotonin reuptake inhibitors (SSRIs) prior to receiving CBT (Kobori, 2011). As very few studies have examined the use of medication-only approaches or approaches of medication combined with CBT, additional case studies in these areas are needed.
While many evidence-based treatments for adolescents have been adapted from treatments designed for adult or child populations, many aspects of adolescent development (i.e., need to balance growing autonomy with dependence on adults, greater emphasis on peers and social relationships) have not been addressed (Weisz & Hawley, 2002). This oversight has produced gaps in adolescent treatment protocols that often result in a lack of attention on relevant social, biological, and psychological aspects of adolescent development and functioning. Domains that should specifically be considered in adolescent care include the relevance of the treatment modality, parental involvement in the treatment process (Payne, Eaton, Mee, & Blount, 2013), and other unique factors among adolescents that affect medication selection when it is provided in tandem with treatment. To this end, we present a clinical case depicting the treatment of an adolescent female with emetophobia.
2 Case Introduction
“Sarah” (pseudonym) is a 15-year-old White female referred to our university-based clinic by her pediatrician for evaluation and treatment of panic attacks. One month prior to the intake, Sarah sought services with her pediatrician and was prescribed 50 mg of Sertraline daily.
3 Presenting Complaints
The Anxiety Disorders Interview Schedule-IV (ADIS-IV; Brown, DiNardo, Barlow, & DiNardo, 1994) was administered due to the frequent comorbidity of and difficulties differentiating between panic disorder and specific phobia (emetophobia; Veale, 2009). Based on the information collected, the diagnosis of specific phobia (emetophobia) was given. Sarah endorsed symptoms of anxiety and weekly panic attacks related to fear of vomiting over the past 6 months. She became anxious and experienced panic attacks when exposed to both internal cues (e.g., nausea, indigestion) and external cues (e.g., hearing about another student throwing up) related to vomiting. Sarah also reported experiencing somatic symptoms (e.g., stomachaches). Sarah and her mother endorsed the occurrence of panic attacks at least weekly (i.e., feelings of being trapped, shortness of breath, accelerated heart rate, sweating, restlessness, and anxiety); however, panic disorder was ruled out because Sarah did not have a fear of recurrent panic attacks and her fear was solely centered on vomiting. Repetitive thoughts of “I don’t feel good” and “I think I’m going to throw up” during times of increased anxiety or in response to internal cues were also present. Sarah identified two precipitating events that led to a worsening of her symptoms: (a) feeling disgust and embarrassment after witnessing her brother vomit during a flight (at age 6), and (b) vomiting several times when she was very ill (at age 9).
Sarah described adjusting her behavior over time so that she could avoid vomiting or situations during which she might encounter vomit. Her avoidance extended across contexts to school, with peers, and at home. She avoided parties where alcohol would be served, skipped class when she was not feeling well or knew someone in class had the flu, avoided certain modes of transportation when traveling (e.g., flying), avoided public toilets, and would not use the word “vomit.” She engaged in safety-seeking behaviors by calling her mother for permission to leave school approximately once every other week when she was worried about getting sick or had heard about someone vomiting. Sarah’s family inadvertently accommodated her avoidance in an attempt to help decrease her anxiety. These accommodations included avoiding cooking or serving foods that smelled “like vomit” to Sarah and allowing Sarah to sleep in a different bedroom when someone in the family was sick to be further away from the sick person.
Psychological services were sought due to the continued worsening of Sarah’s anxiety symptoms; the failure of less intensive, self-guided intervention methods (e.g., distraction); and several approaching developmental milestones (e.g., being close to driving-age, going to college in 2 years) and social events (e.g., wanting to work as a summer camp counselor). During the intake and throughout the course of treatment, Sarah demonstrated strong insight for her developmental level. Sarah’s interactions with her mother were relaxed, supporting Sarah’s and her mother’s report that the two had a close, trusting relationship. Sarah and her mother endorsed high levels of motivation to engage in therapy to (a) better understand Sarah’s symptoms and (b) reduce her symptoms of anxiety.
4 History
No developmental or behavioral concerns were reported. Similarly, Sarah’s history revealed typical development in academic and social domains. She had no history of behavioral or academic difficulties in school. Sarah was described as demonstrating strong social skills and maintaining developmentally appropriate peer relationships. Sarah and her mother noted various extracurricular and hobby activities in which she was involved. Sarah reported having close relationships with many of her family members and reported that she could rely on her parents for support in addressing her anxiety.
5 Assessment
During her intake session, Sarah completed several general self-report measures. Sarah and her mother endorsed ratings in the average range of behavioral and emotional symptoms on the Behavior Assessment System for Children Behavioral and Emotional Screening System–Student Form (Reynolds, Kamphaus, & Vannest, 2011). Sarah also scored in the average range of depressive symptoms on the Childhood Depression Inventory–2 (Kovacs, 2010). Finally, Sarah endorsed high levels of anxiety on the Revised Children’s Manifest Anxiety Scale–Second Edition, and her scores were significantly elevated on the Worry/Oversensitivity subscale (Reynolds & Richmond, 1985).
Specific Phobia of Vomiting Inventory (SPOVI; Veale et al., 2013)
The SPOVI is a 14-item self-report Likert-type scale (0 = not at all to 4 = all the time) measure of symptoms related to emetophobia, including symptom severity. The SPOVI has two subscales (Avoidance and Threat Monitoring) and a Total Emetophobia Score. The SPOVI has good internal reliability (α = .91) and is highly correlated with the Emetophobia Questionnaire (EmetQ-13; r = .82; Veale et al., 2013).
EmetQ-13
The EmetQ-13 (Boschen, Veale, Ellison, & Reddell, 2013) is a brief self-report measure of symptoms of emetophobia. It has good internal consistency (α = .82 to .85) and test–retest reliability (r = .76), and it accurately classifies individuals into emetophobia or non-emetophobia categories 96.2% of the time (Boschen et al., 2013).
6 Case Conceptualization
Sarah’s symptoms are best conceptualized with the tripartite model of anxiety, which encompasses behavioral, physical, and cognitive components (Ollendick, Allen, Benoit, & Cowart, 2011). The physiological symptoms and subsequent cognitive (i.e., thoughts about herself and others vomiting) and emotional (e.g., feelings of disgust or embarrassment, anxiety about hearing someone vomit) reactions Sarah initially felt during her acute illness generalized. As Sarah’s anxiety increased over time, the symptoms became more pronounced and difficult to manage. Cognitively, Sarah associated cues related to vomiting as dangerous. Her repetitive cognitions (e.g., “I think I’m going to throw up”) became conditioned stimuli that served to maintain this anxiety, particularly when combined with her avoidance behaviors and her family members’ willingness to alter their own behavior to accommodate Sarah’s anxiety.
Sarah also experienced physiological responses associated with her anxiety, such as panic symptoms and gastrointestinal distress. Finally, Sarah’s behavioral response of avoidance served to maintain and strengthen her anxiety of the feared stimulus, vomiting. While originally only associated with her acute illness, these behavioral, cognitive, and physiological responses generalized to include any cues that might be associated with illness. This conceptualization was consistent with established cognitive-behavioral models of emetophobia (e.g., Boschen et al., 2013; Veale, 2009). Accordingly, a behavioral approach combined with elements of cognitive therapy was implemented to target Sarah’s specific phobia of vomiting.
7 Course of Treatment and Assessment of Progress
Treatment involved exposure therapy with response prevention and included elements of CBT throughout treatment to challenge cognitive distortions. Exposure sessions predominantly relied on the use of videos. The main course of treatment consisted of 15 total sessions. In addition, 3 months after the final session, three follow-up sessions were held. A more comprehensive overview of the specific components of treatment is provided in the sections below.
Treatment Goals and Plan
Treatment focused on reducing Sarah’s anxiety response to cues associated with vomiting or seeing others vomit. Because Sarah was a minor, her mother was also involved in some of Sarah’s at-home exposures and was informed of treatment progress on a biweekly basis. However, most sessions were conducted with Sarah alone as part of an effort to recognize her autonomy as an adolescent and build rapport. Sarah’s interests and peer relationships were incorporated throughout treatment to maintain rapport and strengthen the therapeutic alliance.
Treatment included psychoeducation (two sessions), skills training in cognitive restructuring (two sessions), exposure therapy (nine sessions), and medication discontinuation and maintenance (four sessions). For an overview of treatment, see Table 1. Treatment was supplemented with medication management and consultation with Sarah’s pediatrician. Sessions were held weekly throughout the main course of treatment, and monthly during the follow-up period of treatment. Weekly homework assignments consisted of skills practice and at-home exposures. For the last five exposure sessions, Sarah began to take a more active and collaborative role in treatment, suggesting ideas for exposure and homework assignments. She brought videos she had found independently to facilitate her in-session exposure exercises.
Session Outline for Treatment of Emetophobia.
Psychoeducation About Anxiety and Development of Coping Skills
The first two sessions focused on formulating a differential diagnosis and providing psychoeducation about anxiety. The clinician utilized a circular heuristic to provide information about the development and maintenance of anxiety. Specifically, the feedback loop of cognitions (e.g., “That food smells like vomit”), emotions (e.g., worry about becoming sick), and physical indicators (e.g., queasy stomach) in the experience of anxiety were discussed. Discussion about how a symptom in one area, like indigestion, could trigger other anxiety responses, like worry and thoughts about feeling sick, was included. The clinician also reviewed with Sarah’s mother specific parental behaviors (e.g., providing reassurance, allowing Sarah to leave school) that may reinforce anxiety.
Cognitive restructuring was introduced in the second session and was used to challenge distorted, unrealistic thoughts that contributed to Sarah’s anxiety. Sarah identified many thoughts that fueled her emetophobia symptoms. These thoughts primarily centered on concerns about herself getting sick or worries of others becoming sick near her. In cognitive restructuring, Sarah was challenged to examine these thoughts critically by identifying evidence for or against these thoughts. For example, when challenging the thought of “I’m going to get sick if someone vomits in the room,” Sarah was asked to identify the number of times in which she actually got sick if someone else vomited. She also identified the many ways in which sickness is transmitted and how being present in the room with someone else vomiting would be unlikely to transmit illness. Based on this critical analysis, Sarah was prompted to revise her initial anxiety-provoking thought to be more in line with her reality (e.g., “Although it would be unpleasant if someone vomited in the room, it is highly unlikely that I would get sick”). These revised thoughts were then linked with reduced feelings of anxiety. As another example, when misinterpreting gastrointestinal symptoms to indicate impending vomiting, Sarah was encouraged to consider alternate explanations such as “I am getting hungry". This, in turn, reduced the occurrence of anxious thoughts and physiological reactivity. In the third session, the cycle of anxiety was reviewed, exposure therapy was discussed, and a fear hierarchy was created (see Table 2).
Hierarchy of Feared Stimuli Associated With Emetophobia.
Note. Session = session number(s) during which the item was addressed. SUDS = Subjective Units of Distress Scale.
Exposure Therapy and Response Prevention
Exposure therapy began in the fourth session. Exposures predominantly consisted of viewing others vomit, as Sarah’s symptoms of emetophobia were largely centered on her physiological reactivity in response to her own or others’ perceived gastrointestinal discomfort. To maintain a trusting relationship and a strong therapeutic alliance, Sarah was reminded about the type of videos she would be watching at the beginning of each session that involved exposures (e.g., banana and Sprite® challenge), but was not told specifics about the videos (e.g., at what point in the video someone would vomit, whether anyone in the video would vomit). During all exposures, Sarah was not allowed to engage in her avoidance behaviors, meaning she was not allowed to leave the room or to look away from images during exposures. This was accomplished through discussion of the behavioral expectations for exposures and by watching Sarah during exposures to ensure she did not look away. If Sarah looked away, she was verbally encouraged to resume looking at the stimulus. There were no situations during which Sarah looked away for longer than a few seconds or attempted to leave the room. Similarly, Sarah was instructed to refrain from an escape-based response during at-home exposures.
In addition to exposures in the therapeutic setting, Sarah was provided with homework assignments that involved viewing pre-selected videos (e.g., people vomiting during food challenges, people being filmed vomiting with the flu). Sarah was also asked to bring food to sessions to eat during some of her exposures. Over the course of treatment, Sarah began to select her own videos for her at-home exposures. Sarah and the clinician also agreed upon select in-vivo exposures at home, some of which required very specific situations that could not be effectively simulated in the clinic setting. For instance, the clinician attempted to feign illness and have a confederate do the same, but Sarah suspected that these situations were not real, and thus they did not elevate her subjective units of distress (SUDS) level. Therefore, Sarah and the clinician planned for Sarah to remain around ill family members of friends without engaging in avoidance behaviors. In other situations that were easier to coordinate, Sarah went to places she had previously avoided for fear of seeing vomit (e.g., college football games/tailgating, amusement park).
The first exposure sessions included exposure to audio files of coughing and burping, and also included the clinician saying “vomit” and synonyms of the word vomit (e.g., ralph, upchuck, puke) in vivo . Within the next session, cartoon-based videos of vomiting were shown to Sarah due to her low levels of distress from lower level items on her hierarchy (e.g., the ipecac scene from a cartoon called Family Guy®). Sessions 6 through 12 consisted of videos depicting real people vomiting. The therapist integrated social media to provide the in-session exposures, because the videos available on these platforms appeared to be more relevant for Sarah, as judged by her SUDS ratings (0-10 scale, 10 representing highest anxiety). Such ratings were taken throughout exposures to ensure Sarah’s SUDS was acceptably low before the session terminated. During these sessions, Sarah’s SUDS ratings ranged from “6” to “8.” Each video stimulus was shown in repetition until at least a 50% reduction in Sarah’s SUDS rating was achieved. Finally, each exposure session ended on a high note, with Sarah selecting a fun video clip to watch as a reward for her participation in the exposure(s) during that session.
8 Complicating Factors
Because Sarah was an adolescent during the course of treatment, the clinician, Sarah, and her mother often checked in to discuss expectations and roles of each person involved in treatment. In addition, although Sarah was somewhat motivated to begin treatment, she also expressed a desire to embed discussion of other into treatment. In recognizing that exposure therapy would be challenging and fear-evoking, Sarah suggested such practices be incorporated into treatment to help motivate her to come to treatment. Both considering the role Sarah’s mother played in treatment and incorporating factors that were important to Sarah based on her developmental level were instrumental in the success of the treatment approach presented in this case study.
Sarah’s mother was involved in exposures at home and was informed of treatment progress on a regular basis. In fact, Sarah’s mother was brought into the therapy room with Sarah and the therapist for 10-min catch-up sessions biweekly. Prior to bringing Sarah’s mother into the therapy room, the clinician and Sarah would review content that would be discussed with Sarah’s mother in an effort for the therapist to maintain good rapport with Sarah. Sarah and the clinician jointly explained Sarah’s progress in treatment along with what Sarah had learned in session to her mother, and Sarah increased her involvement in this process as she felt ready to do so.
9 Access and Barriers to Care
Ethical considerations were of principle concern when establishing the exposure hierarchy. Although the client had an extreme anxiety response to seeing others vomit or to vomiting herself, no real-life instances of vomiting (either by the client or others) were encouraged in treatment. This was a calculated risk, because avoiding the most distressing, real-life situations could have resulted in less salient exposures and therefore poorer treatment outcomes. However, the general principles proposed within the ethical code suggest that forcing the client herself or another individual to vomit would violate Principle A: Beneficence and Nonmaleficence and Principle E: Respect for People’s Rights and Dignity. Thus, exposures had to be selected carefully and had to be developed in a creative fashion to afford Sarah the opportunity to confront her anxiety without inducing vomiting in session. Indeed, given the high ratings obtained from video exposures and both objective and subjective data indicating response to treatment, the authors feel that the decision to avoid such extreme measures was supported.
Treatment Termination and Medication Discontinuation
As mentioned earlier, Sarah was prescribed Sertraline approximately 1 month prior to the onset of treatment. It is possible that the Sertraline may have affected the course of treatment in two ways. First, the medication likely decreased Sarah’s anxiety response, which may have enabled the exposures to progress more quickly with the additional support. Second, Sarah partially attributed her progress in treatment to her use of Sertraline, which made it more difficult to motivate Sarah to stop taking Sertraline toward the end of treatment.
However, Sarah ultimately endorsed confidence in her ability to terminate treatment following minimal distress at an exposure that had resulted in high levels of distress in prior sessions. With the exception of concerns about vomiting herself, which could not ethically be accomplished in a therapeutic setting, she had mastered her fear hierarchy. Sarah reported that she felt she had made significant progress in treatment and was able to cite several instances during which she had indirect exposure to someone vomiting (e.g., hearing her younger brother vomiting in the bathroom, seeing a character vomit on a television show) without having significantly elevated distress. Given her gains and self-reported confidence, Sarah and the clinician agreed to stop exposures and focus on gradually discontinuing psychotropic medication. Following this discussion, her mother scheduled an appointment with Sarah’s pediatrician to discuss medication tapering.
Three months after her final exposure session, Sarah returned for three monthly follow-up appointments. She had not experienced panic attacks or extreme symptoms of anxiety during the 3-month break and was gradually decreasing her medication dose. Psychotropic medication was fully discontinued by the last follow-up session, with no instance of panic attacks or anxiety reported.
As can be seen in Figures 1 and 2, Sarah’s scores on the SPOVI and EmetQ-13 decreased over time. There is one noticeable spike in Sarah’s SPOVI score in Session 13, which was partially because this was the session during which we did her most difficult exposure for the first time (i.e., watching someone with the flu vomit in distress). Sarah’s Total SPOVI and Avoidance Scale scores decreased to nonclinical levels by the end of treatment. Indeed, the reliable change indices (RCI) for these measures were calculated to demonstrate statistically meaningful change (Unicomb, Colyvas, Harrison, & Hewat, 2015; Wise, 2004) and found to be all significant: SPOVI (RCI = 13.85, Effect size = 1.24), EmetQ-13 (RCI = 3.36, Effect size = 6.87).
Sarah’s scores on the SPOVI over time.
Sarah’s scores on the Emetophobia Questionnaire (EmetQ-13) over time.
10 Follow-Up
At 3-month follow-up, Sarah’s SPOVI Total score remained at a nonclinical level. Sarah’s baseline Total EmetQ-13 scores were clinically elevated, yet over the course of treatment, Sarah’s EmetQ-13 scores decreased steadily until the final session. At her 3-month follow-up appointment, Sarah’s score on the EmetQ-13 appeared stable. Although her scores never fell below the most sensitive and specific clinical cutoff score of 22, this cutoff score was developed for adult sample and is not normed for adolescents.
In addition to her scores on self-report measures, Sarah’s levels of anxiety decreased across sessions, as indicated by her SUDS ratings to the increasingly challenging exposures. At the beginning of an exposure session involving a new step up on the fear hierarchy developed by Sarah, her SUDS would fall between “6” and “8” and reach a “2” or “3” by the end of the session. Throughout the course of therapy, Sarah also noted instances at home where she would have previously engaged in avoidance behaviors, but instead challenged herself to refrain from engaging in such behaviors. For example, Sarah did not call her mother asking to leave school when her stomach began to hurt and she did not change the channel if a character vomited during a show she was watching. Such alterations in her behavior were strong personal indicators for Sarah of her success in therapy.
At the end of treatment, Sarah displayed marked improvement. She was able to remain at school and sports practices, be around sick family members, and no longer call her mother from school or social events to escape her anxiety. At her first 3-month follow-up appointment, Sarah reported she had been able to work as a camp counselor where she was exposed to vomit without elevated levels of anxiety. At treatment termination, Sarah no longer met diagnostic criteria for specific phobia (emetophobia), as she was able to function without impairment and no longer experienced panic attacks.
11 Treatment Implications of the Case
This case study evidenced the use of developmentally sensitive treatment including exposure therapy alongside selected skills from CBT to treat an adolescent female with specific phobia (emetophobia) in an outpatient training clinic. Many elements within our treatment program aligned with treatment recommendations made by Boschen (2007) and Veale (2009). However, the therapeutic process was further enhanced through the inclusion of social media, supportive parental involvement, and adjunct psychotropic medication. The success of these methods suggests treatment recommendations for emetophobia could be improved through inclusion of social media and other factors that were less prominent when the standard treatment for emetophobia was developed (e.g., Boschen, 2007; Veale, 2009). Although Sarah was the primary agent of change in treatment, her mother played an integral role in the therapeutic process. The dynamic between Sarah and her mother was helpful in the beginning of treatment, as Sarah’s mother encouraged Sarah to do her exposures and to attend therapy. Over time, however, primary treatment responsibility transitioned to Sarah, as her mother gradually encouraged Sarah’s increased autonomy in treatment.
Adolescence is a pivotal developmental stage for the onset of emetophobia and our field has much to learn by providing services to and conducting research with adolescents. Our developmentally informed methods allowed Sarah to assume an active, collaborative role and successfully complete the entire course of treatment. The success of these methods supports the importance of a combined approach in the treatment of adolescents with emetophobia, as well as the importance of continued assessment and consideration of the ways psychosocial and developmental factors may interact with treatment response.
When experiencing symptoms of panic attacks, the vast majority of clients will seek consultation with a physician, not a psychologist (e.g., Katerndahl & Realini, 1995). Sarah’s case was consistent with this finding, as she initially sought services with her pediatrician. Moreover, research indicates that at least half of adults with emetophobia have experienced panic attacks associated with their concerns about vomit and vomiting (Lipsitz et al., 2001). It is important that medical professionals and psychologists are well-informed about the co-occurrence of emetophobia and panic attacks, and that the fields continue partnering together to treat the disorder. This case highlights the importance of collaboration between physicians and psychologists in delivering combined treatment for psychological disorders. Engaging in regular consultation to promote continuity of care may be especially important for establishing trust and increasing buy-in when working with adolescents and their families.
12 Recommendations to Clinicians and Students
Three factors were conceptualized as integral to the success of treatment. First, the clinician engaged in exposures outside of sessions to prepare for sessions involving the more extreme videos depicting vomiting, because the content used during exposures was graphic and produced strong physiological arousal in the clinician. Second, the use of social media was a helpful resource, as the Internet provided many videos of a diverse group of individuals vomiting in a variety of settings. In addition, Sarah’s progress indicates that using social media with teenagers may increase compliance with homework. For example, Sarah was far more compliant with her homework when it involved watching anxiety-provoking video clips rather than when she was asked to log relaxation skills practice. Finally, it was important to balance the level of parental involvement within the present adolescent case study. The authors would recommend that individuals following this treatment protocol involve parents in exposures at home on a regular basis when possible. It is important that parents understand contributing factors to emetophobia to effectively address maintaining environmental factors of the phobia. In addition, encouraging parents to play a more active role in homework may both (a) ensure homework is completed and (b) help the parents learn new non-avoidant patterns.
Given the difficult nature of treatment for emetophobia, motivation and engagement may be a significant barrier to treatment. For adolescents who are less motivated to participate in treatment, it can be helpful to use motivational interviewing techniques (for a review, see Erickson, Gerstle, & Feldstein, 2005), which are patient-centered techniques that are developmentally appropriate for use with adolescents. Such techniques may involve the use of client feedback pertaining to the effects of their current behavior or discussing the decisional balance of engaging in therapy and implementing behavioral change. In addition, motivational interviewing techniques support self-efficacy within the client. A second technique to motivate an adolescent to actively engage in the therapeutic process may be to develop a behavioral contract either individually with the adolescent or using problem-solving family therapy (D’Zurilla & Nezu, 2010).
No literature to date has empirically examined the treatment of emetophobia in adolescence. Treatment for adolescents often parallels treatment with an adult, but a developmentally informed approach is strongly recommended over the downward extension of treatment for adults to treatment with adolescents (Weisz & Hawley, 2002). Based on such recommendations, the present case study was informed by cognitive, social, and biological components specific to Sarah’s presentation and emetophobia. Treatment focused on utilizing exposure therapy and cognitive-behavioral strategies to address symptoms of emetophobia and panic attacks. Moreover, treatment was tailored to include physician consultation and psychotropic medication, parental involvement during select session work and assigned homework, and the use of social media to maintain Sarah’s engagement in treatment. The inclusion of exposure in combination with selected cognitive and behavioral skills was critical to address the multifacted nature of Sarah’s anxiety, including her distorted, anxious cognitions, behavioral avoidance, and conditioned physiological symptoms. The importance of using developmentally informed treatment was supported not only by the success of treatment, but is also evidenced by the increasing levels of independence with which Sarah engaged in her at-home sessions of exposure therapy throughout the course of therapy.
Results from the present case study illustrate that developmentally informed treatment featuring exposure-based therapy with elements of CBT effectively reduced symptoms of emetophobia for an adolescent female. While these results are promising, a singular case study has limited generalizability to the broader population. Thus, it is imperative that further research is conducted to examine the use of this approach in adolescents presenting with emetophobia. In summary, treatment of emetophobia among adolescents can have a positive impact on socioemotional and physical well-being for these youths who are at a critical developmental point in their lives. Furthermore, future studies should continue to incorporate domains specific to adolescent care into treatment for emetophobia, including parental involvement in the treatment process and unique neurobiological factors among adolescents that affect medication selection when it is provided in tandem with treatment.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.