Anyone with an anxiety disorder will come up with various ways to feel safer. These are described variously as coping skills, compulsions, and rituals. We prefer the term safety behaviors because that describes the purpose of the action. Attempting to escape or finding a way to be safe is a biological demand in the face of real or perceived danger.
We are all ‘hardwired’ to respond instantly and intensely to danger. That happens in fractions of seconds before we can interpret whether the danger is real or not. That is a very reliable system and we are constantly fine-tuning it as we learn more and more about the world and ourselves. We are all trying to figure out what is dangerous and what is not. Although we are not always aware of it, this part of our nervous system impacts us continually, even during sleep.
However, the system is imperfect and sometimes the result is excessive anxiety or an anxiety disorder. An anxiety disorder, among other things, is when the reaction is significantly incongruent with the actual danger according to one’s own view or that of objective observers.
Part of how our normally reliable alarm system contributes to an anxiety disorder is the attempt to be safe. These attempts to be safer, paradoxically, end up perpetuating the excessive fear. When something is mistakenly viewed as catastrophic then the attempts to feel safe ‘confirm’ that something is dangerous and because it is avoided, experiences and information that would correct the mistaken belief don’t take place. Repetition reconfirms that something is dangerous as well as the belief that one is okay only because of the safety behaviors.
As emetophobia gains steam, children (and adults) create safety behaviors. Over time, these grow and become more elaborate. These are obeyed with great intensity. High anxiety is a tyrant and demands obedience or else. If you haven’t had an anxiety disorder, it is hard to imagine the urgency and power it wields over someone’s life. If a child is pushed in a way that interferes with a safety behavior it will often lead to a meltdown of the first order. This is NOT evidence of bad character or oppositional behavior, it is terror.
Most safety behaviors from emetophobia are common to all, but we are ever amazed by the creativity of kids. As extreme or peculiar as some of these may seem to an observer, they are all just attempts to feel safe. Part of treatment is to persuade patients that giving these up will actually reduce the anxiety. However, just the opposite is the experience of someone with emetophobia. When they do things to feel safer, they will get some relief, at least at the beginning. The thought of stopping these is terrifying. Likely they have never stopped a safety behavior long enough to have the experience of the anxiety going down. Explaining how this works, starting the process of elimination slowly, and doing it gradually are crucial.
We provide an extensive symptom and safety behavior list located here and it can be downloaded and used freely. Below is a modified list of some of the most common safety behaviors occurring in children. These are all specifically related to the fear of throwing up. For example, a child might be anxious about a cold but the actual fear is if the illness will lead to throwing up. Or a child may not want to go over to a friend’s house for dinner, not because of social or separation anxiety, but because something served could cause them to get nauseated and throw up.
Essentially, these are all ways of AVOIDING anything that might lead to throwing up.
- Scanning for people who look like they might be sick or talk about being sick. If someone does get sick they might be avoided for a very long time, maybe indefinitely.
- Frequently scanning one’s body for any sign of illness (ex. Nausea, feeling in throat, fever, etc.)
- Asking for reassurance about whether one is sick currently or will get sick in the near future.
- Asking adult/parent to check body temperature (e.g., hand on forehead or thermometer).
- Checking on whether food is cooked enough, has been left out, or has expired. Avoid eating places where that information is not available (e.g., a friend’s house or restaurant).
- Avoiding anything that has been in contact with a sick person (e.g., desk, chair, school supplies, toys, etc.)
- Avoid sleeping alone in case they might get sick in the night.
- Avoid situations that might cause motion sickness (e.g., 3-D movie, travel, boats, roller coasters, swings, etc.)
- Avoid getting overheated.
- Avoid certain foods that could cause vomiting.
- Stop eating before feeling full.
- Eating very slowly or only in certain settings.
- Avoid being away from the safe adult(s).
- Worrying frequently about throwing up and planning ways to stay safe.
- Complains a lot about not feeling good (may be general but if asked specifically probably throat or stomach).
- Reactive or avoids references to throwing up in books, tv, movies, YouTube, TikTok, etc.
- Will avoid and may require others to not say anything related to throwing up.
- Excessive decontamination (or quarantine) of one’s body or items that may be contaminated with germs (e.g., excessive handwashing, cleaning devices, or showers).
- School refusal if there is a possibility of getting the norovirus.
- Excessive use of things like Tums, ginger, peppermint, or other medications to prevent getting sick or must have the available at all times.
- Performing superstitious behaviors (e.g., not wearing clothing associated with throwing up).
- Doing subtle things like swallowing, pulling a shirt over the nose, mental neutralizing, etc.