Surviving Anxiety

I've tried therapy, drugs, and booze. Here’s how I came to terms with the nation's most common mental illness.
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Stupefied by Thorazine and exhausted by an afternoon of anxiety-induced gastric distress, the author, age 12, before a classmate's bar mitzvah in 1982 (Courtesy of the Stossel family)

I struggle with emetophobia, a pathological fear of vomiting, but it’s been a while since I last vomited. More than a while, actually: as I type this, it’s been, to be precise, 35 years, two months, four days, 23 hours, and 34 minutes. Meaning that more than 83 percent of my days on Earth have transpired in the time since I last threw up, during the early evening of March  7, 1977, when I was 7 years old. I didn’t vomit in the 1980s. I didn’t vomit in the 1990s. I haven’t vomited in the new millennium. And needless to say, I hope to make it through the balance of my life without having that streak disrupted. (Naturally, I was reluctant even to type this paragraph, and particularly that last sentence, for fear of jinxing myself or inviting cosmic rebuke, and I am knocking on wood and offering up prayers to various gods and Fates as I write this.)

What this means is that I have spent, by rough calculation, at least 60 percent of my waking life thinking about and worrying about something that I have spent zero percent of the past three-plus decades doing. This is irrational.

And yet, an astonishing portion of my life is built around trying to evade vomiting and preparing for the eventuality that I might throw up. Some of my behavior is standard germophobic stuff: avoiding hospitals and public restrooms, giving wide berth to sick people, obsessively washing my hands, paying careful attention to the provenance of everything I eat.

But other behavior is more extreme, given the statistical unlikelihood of my vomiting at any given moment. I stash motion-sickness bags, purloined from airplanes, all over my home and office and car in case I’m suddenly overtaken by the need to vomit. I carry Pepto-Bismol and Dramamine and other antiemetic medications with me at all times. Like a general monitoring the enemy’s advance, I keep a detailed mental map of recorded incidences of norovirus (the most common strain of stomach virus) and other forms of gastroenteritis, using the Internet to track outbreaks in the United States and around the world. Such is the nature of my obsession that I can tell you at any given moment exactly which nursing homes in New Zealand, cruise ships in the Mediterranean, and elementary schools in Virginia are contending with outbreaks. Once, when I was lamenting to my father that there is no central clearinghouse for information about norovirus outbreaks the way there is for influenza, my wife interjected. “Yes, there is,” she said. We looked at her quizzically. “You,” she said.

An astonishing portion of my life is built around trying to evade vomiting and preparing for the eventuality that I might throw up.

For several years, in my mid-30s, I worked with a psychologist in Boston, Dr. M., who had a practice at one of the city’s academic medical centers. I had originally sought treatment for a number of phobias, but after several months of consultations, Dr. M. determined—as several other therapists, before and since, also have—that at the core of my other fears lay my fear of vomiting (for instance, I’m afraid of airplanes partly because I might get airsick), so she proposed we concentrate on that.

“Makes sense to me,” I concurred.

She explained that we would try to apply the principles of what’s known as exposure therapy toward extinguishing my emetophobia.

“There’s only one way to do that properly,” she said. “You need to confront the phobia head-on, to expose yourself to that which you fear the most.”

Uh-oh.

“We have to make you throw up.”

No. No way. Absolutely not.

She explained that a colleague had just successfully treated an emetophobe by giving her ipecac syrup, which induces vomiting. The patient, a female executive who had flown in from New York to be treated, had spent a week undergoing exposure therapy. Each day she would take ipecac administered by a nurse, vomit, and then process the experience with the therapist—“decatastrophizing” it, as the cognitive-behavioral therapists say. When she flew back to New York, Dr. M. reported, she was cured of her phobia.

I remained skeptical. Dr. M. gave me an article from an academic journal reporting on a clinical case of emetophobia successfully treated with this kind of exposure.

“This is just a single case,” I said. “It’s from 1979.”

“There have been lots of others,” she said, and reminded me again of her colleague’s patient.

“I can’t do it.”

“You don’t have to do anything you don’t want to do,” Dr. M. said. “I’ll never force you to do anything. But the only way to overcome this phobia is to confront it. And the only way to confront it is to throw up.”

We had many versions of this conversation over the course of several months. I trusted Dr. M., who was kind and smart. So one autumn day I surprised her by saying I was open to thinking about the idea. Gently, reassuringly, she talked me through how the process would work. She and the staff nurse would reserve a lab upstairs for my privacy and would be with me the whole time. I’d eat something, take the ipecac, and vomit in short order (and I would survive just fine, she said). Then we would work on “reframing my cognitions” about throwing up. I would learn that it wasn’t something to be terrified of, and I’d be liberated.

She took me upstairs to meet the nurse. Nurse R. showed me the lab and told me that taking ipecac was a standard form of exposure therapy; she said she’d helped preside over a number of exposures for now-erstwhile emetophobes. “Just the other week, we had a guy in here,” she said. “He was very nervous, but it worked out just fine.”

We went back downstairs to Dr. M.’s office.

“Okay,” I said. “I’ll do it. Maybe.”

Over the next few weeks, we’d keep scheduling the exposure—and then I’d show up on the appointed day and demur, saying I couldn’t go through with it. I did this enough times that I shocked Dr. M. when, on an unseasonably warm Thursday in early December, I presented myself at her office for my regular appointment and said, “Okay. I’m ready.”

The exercise was star-crossed from the beginning. Nurse R. was out of ipecac, so she had to run to the pharmacy to get some more while I waited for an hour in Dr. M.’s office. Then it turned out that the upstairs lab was booked, so the exposure would have to take place in a small public restroom in the basement. I was constantly on the verge of backing out.

What follows is an edited excerpt drawn from the dispassionate-as-possible account I wrote up afterward, on Dr. M.’s recommendation. (Writing an account of a traumatic event is a commonly prescribed way of trying to forestall post-traumatic stress disorder after a harrowing experience.) If you’re emetophobic yourself, or even just a little squeamish, you might want to skip over it.

We met up with Nurse R. in the basement restroom. After some discussion, I took the ipecac.

Having passed the point of no return, I felt my anxiety surge considerably. I began to shake a little. Still, I was hopeful that sickness would strike quickly and be over fast and that I would discover that the experience was not as bad as I’d feared.

Dr. M. had attached a pulse-and-oxygen-level monitor to my finger. As we waited for the nausea to hit, she asked me to state my anxiety level on a scale of one to 10. “About a nine,” I said.

By now I was starting to feel a little nauseated. Suddenly I was struck by heaving and I turned to the toilet. I retched twice—but nothing was coming up. I knelt on the floor and waited, still hoping the event would come quickly and then be over. The monitor on my finger felt like an encumbrance, so I took it off.

After a time, I heaved again, my diaphragm convulsing. Nurse R. explained that dry heaving precedes the main event. I was now desperate for this to be over.

The nausea began coming in intense waves, crashing over me and then receding. I kept feeling like I was going to vomit, but then I would heave noisily and nothing would come up. Several times I could actually feel my stomach convulse. But I would heave and … nothing would happen.

My sense of time at this point gets blurry. During each bout of retching, I would begin perspiring profusely, and once the nausea passed, I would be dripping with sweat. I felt faint, and I worried that I would pass out and vomit and aspirate and die. When I mentioned feeling light-headed, Nurse R. said that my color looked good. But I thought she and Dr. M. seemed slightly alarmed. This increased my anxiety—because if they were worried, then I should really be scared, I thought. (On the other hand, at some level I wanted to pass out, even if that meant dying.)

After about 40 minutes and several more bouts of retching, Dr. M. and Nurse R. suggested I take more ipecac. But I feared a second dose would subject me to worse nausea for a longer period of time. I worried that I might just keep dry heaving for hours or days. At some point, I switched from hoping that I would vomit quickly and be done with the ordeal to thinking that maybe I could fight the ipecac and simply wait for the nausea to wear off. I was exhausted, horribly nauseated, and utterly miserable. In between bouts of retching, I lay on the bathroom tiles, shaking.

A long period passed. Nurse R. and Dr. M. kept trying to convince me to take more ipecac, but by now I just wanted to avoid vomiting. I hadn’t retched for a while, so I was surprised to be stricken by another bout of violent heaving. I could feel my stomach turning over, and I thought for sure that this time something would happen. It didn’t. I choked down some secondary waves, and then the nausea eased significantly. This was the point when I began to feel hopeful that I would manage to escape the ordeal without throwing up.

Nurse R. seemed angry. “Man, you have more control than anyone I’ve ever seen,” she said. (At one point, she asked peevishly whether I was resisting because I wasn’t prepared to terminate therapy yet. Dr. M. interjected that this was clearly not the case—I’d taken the ipecac, for God’s sake.) Eventually—several hours had now elapsed since I’d ingested the ipecac—Nurse R. left, saying she had never seen someone take ipecac and not vomit. [I’ve since read that up to 15 percent of people—a disproportionate number of them surely emetophobes—don’t vomit from a single dose of ipecac.] After some more time, and some more encouragement from Dr. M. to try to “complete the exposure,” we decided to “end the attempt.” I still felt nauseated, but less so than before. We talked briefly in her office, and then I left.

Driving home, I became extremely anxious that I would vomit and crash. I waited at red lights in terror.

When I got home, I crawled into bed and slept for several hours. I felt better when I woke up; the nausea was gone. But that night I had recurring nightmares of retching in the bathroom in the basement of the center.

The next morning I managed to get to work for a meeting—but then panic surged and I had to go home. For the next several days, I was too anxious to leave the house.

Dr. M. called the day after the ordeal to make sure I was okay. She clearly felt bad about having subjected me to such a horrible experience. Though I was traumatized, her sense of guilt was so palpable that I felt sympathetic toward her. At the end of the account I composed at her request, which was accurate as far as it went, I masked the emotional reality of what I thought (which was that the exposure had been an abject disaster and that Nurse R. was a fatuous bitch) with an antiseptic clinical tone. “Given my history, I was brave to take the ipecac,” I wrote.

I wish that I had vomited quickly. But the whole experience was traumatic, and my general anxiety levels—and my phobia of vomiting—are more intense than they were before the exposure. I also, however, recognize that, based on this experience in resisting the effects of the ipecac, my power to prevent myself from vomiting is quite strong.

Stronger, it seems, than Dr. M.’s. She told me she’d had to cancel all her afternoon appointments on the day of the exposure—watching me gag and fight with the ipecac had evidently made her so nauseated that she spent the afternoon at home, throwing up. I confess I took some perverse pleasure from the irony here—the ipecac I took made someone else vomit—but mainly I felt traumatized. It seems I’m not very good at getting over my phobias but quite good at making my therapists sick.

I continued seeing Dr. M. for a few more months—we “processed” the botched exposure and then, both of us wanting to forget the whole thing, turned from emetophobia to various other phobias and neuroses—but the sessions now had an elegiac, desultory feel. We both knew it was over.

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Scott Stossel is the editor of The Atlantic magazine and the author of the New York Times bestseller My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind and the award-winning Sarge: The Life and Times of Sargent ShriverMore

Scott StosselScott Stossel has been associated with the magazine since 1992 when, shortly after graduating from Harvard, he joined the staff and helped to launch The Atlantic Online. In 1996, he moved to The American Prospect where, over the course of seven years, he served as associate editor, executive editor, and culture editor. He rejoined the Atlantic staff in 2002.

His articles have appeared in a wide array of publications, including The New Yorker, The New Republic, The New York Times, The Washington Post, and The Boston Globe. His 2004 book, Sarge: The Life and Times of Sargent Shriver, inspired The Boston Globe to write, "Scott Stossel's superb new biography is an extraordinary achievement," while Publisher's Weekly declared, "This is a superbly researched, immensely readable political biography." His most recent book, My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind, became a top-ten New York Times bestseller in its first week of publication.

Within the Atlantic offices, Scott will be forever remembered as the managing editor who oversaw the magazine's 2005 move to Washington from Boston, where it had been based since its founding in 1857. Under Scott's supervision, the magazine shifted all of its operations from Boston's North End to the Watergate building, all the while producing issues that were later nominated for National Magazine Awards.

Along with writing and editing, Scott has taught courses in the American Studies Department at Trinity College. He lives with his family in Washington, D.C.

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