The parents of a beautiful 9-year-old girl were exasperated when they all arrived at a mood and anxiety disorders unit in New York where I was working as a newly minted psychologist.
They needed an explanation for their daughter’s excessive worries about illness and the behaviors she engaged in to keep from getting sick. She was preoccupied with germs, washed her hands often, obsessed about the slightest tummy ache, and was terrified to be around people who might be sick.
These fears had started gradually the year before, with no obvious cause. The anxiety had grown so bad that their once-well-behaved daughter now often tried to skip school, throwing tantrums so she wouldn’t have to mingle with “sick kids.” She was avoiding fun events, too, refusing to go to an amusement park with her class.
The girl had already been evaluated and treated for “anxiety” by a private psychologist, but the talk therapy didn’t work. The girl had become more anxious over time. The parents had ended that treatment and were now seeking a second opinion.
The parents described a normal pregnancy and birth. Their infant daughter was not shy or inhibited, unlike so many others who later develop full-blown anxiety as children. They recalled her as happy and gregarious. Developmental milestones had been met on time. Her growth was normal, her vaccinations had occurred on schedule, and she had never been hospitalized. She did well at school, was sought-after by peers, and was adored by her parents.
When I asked the family general questions to establish rapport, the girl was attentive, open, even chatty. This all changed as soon as I began asking her about her worries and odd behaviors; she became visibly fearful. Via a structured interview, I wanted to understand the core fear underneath all her symptoms. But no matter the question, her answer was always that she was afraid to “get sick.”
Her concerns with hand-washing and extreme measures to avoid germs could argue for a diagnosis of contamination obsessive-compulsive disorder, the most common type. But her repetitive behaviors were just not repetitive enough. Plus, there was no history of OCD in the family.
Hypochondriasis was possible, too. Such patients are anxious about illness and brood about it. But it typically begins in adults in their 20s to 30s, so she was a bit young. Moreover, these patients repeatedly visit physicians already convinced they have a disease, whereas this little girl hated going to doctors lest she “get sick” from a patient there.
I also had to consider generalized anxiety disorder, where an individual is chronically worried, often about their own or others’ health, and has bodily complaints, such as stomachaches. But the parents did not describe this child as a worrier. Her worries lacked the usual variety seen in GAD, which include school, friends, and mistakes of all kinds.
This could be a veiled case of separation anxiety disorder, where the child’s core fear is that something bad will happen to them or their parents when separated and that there will be no one left to care for them. This could explain why she was refusing to separate from her parents to go to school or attend fun social events. But she had no difficulties separating from them when left at home with a babysitter. She had no problems sleeping alone or being with me when her parents left my office.
I was about to exasperate her parents again by offering the unsatisfying anxiety disorder not otherwise specified, when, finishing up the evaluation, I asked whether there were any other behaviors the parents had not mentioned.
Yes, they said, she might have an eating disorder.
“Because she can be weird about food,” they answered, going on to describe her reluctance to eat quickly, eat to fullness, or eat a lot of junk food. “And,” they said, “she’s always asking us to check dates on food labels and refuses to eat foods if they are even close to their expiration dates.”
The lightbulb went on. I turned to the girl: “When you say you are afraid of ‘getting sick,’ do you specifically mean vomiting?” She burst into tears at the word.
Vomiting phobia – of course! There is not much about this in the literature, but as I’ve come to know in my years of practice since, there’s a lot of vomit phobia in anxiety clinics. Such individuals may have never had a particularly terrible bout of vomiting (like my patient, who had last vomited a few months before symptom onset and was back at school after a day).
Rather, the phobia is caused by the gradual avoidance of all things that might cause vomiting: being around sick people, eating too fast or too much, going on amusement park rides, having a tummy ache, seeing someone else vomit, even saying the word vomit. All this avoidance leads to the distorted belief that vomiting would be unbearable, leading to more avoidance and more fear.
Treatment, as for all phobias, is fairly straightforward. Phobias call for cognitive-behavioral therapy (CBT) with an emphasis on exposure, gradually and repeatedly exposing the patient to all that she has been avoiding until she can tolerate the fear, or not even experience much fear at all.
The girl would go on to recover well with CBT.
But that first day, we started with simply having her say the word vomit over and over until she was bored. Then we moved on to barf.
Katherine Dahlsgaard is lead psychologist of the Anxiety Behaviors Clinic at the Children’s Hospital of Philadelphia.