









































87

Graduate Student Journal of Psychology
2022, Vol. 19

Copyright 2022 by the Department of  Counseling and Clinical Psychology
Teachers College, Columbia University

Afraid to vomit? The relationship between temperamental 
fear, emetophobia symptoms, and the impact of sex

Jennifer A. Petell1,  Molly E. Wickenhauser,1  and  Danielle J. Maack,1,2

1Department of Psychology, University of Mississippi
2 Delta Autumn Consulting

Emetophobia, the specific phobia of vomiting (SPOV), is an anxiety disorder associated with a persistent fear of 
emesis. The temperament of fear is evident in phobic and anxiety disorders, which behaviorally manifests through 
a sensitivity in the fight, flight, freeze system (FFFS). The present study aimed to test specific associations between 
these constructs. Undergraduate students (N= 186) completed self-report measures assessing symptoms of emeto-
phobia, the FFFS, and general anxiety. Correlational analyses were used to test initial relations, followed by regres-
sion analyses to assess the unique contribution of temperamental fear to the emetophobia symptom experience. 
Significant positive correlations were found between emetophobia symptoms with anxiety symptoms and the overall 
temperament of fear. However, only the fight response of the FFFS was significantly associated with symptoms of 
emetophobia. Further regression analyses demonstrated that the fight response did not uniquely predict emeto-
phobia symptoms above and beyond anxiety. However, post-hoc analyses illustrated sex moderated the relationship 
between temperamental fear and emetophobia symptoms, such that the relationship was significantly stronger for 
male participants than female participants. Results of this study expand upon the current conceptualization of 
emetophobia to incorporate underlying temperamental vulnerabilities and sex differences, which may function to 
exacerbate and/or maintain symptoms.
Keywords: emetophobia; specific phobia of vomiting (SPOV); fight, flight, freeze system (FFFS); fight, flight, freeze 
questionnaire (FFFQ); sex differences

 The specific phobia of vomiting (SPOV), also 
known as emetophobia, is a specific phobia character-
ized by a marked fear of emesis (self or other). Though 
symptoms have a mean age of onset occurring be-
tween 7.5 to 15.7 years, symptoms may develop and 
frequently persist beyond young adulthood (Keyes & 
Veale, 2018). In fact, symptoms are pervasive and per-
sist for an average duration of 25.9 years before indi-
viduals seek treatment (Keyes et al., 2017; Lipsitz et al., 
2001). Although inconsistent (Veale et al., 2015), prev-
alence estimates of emetophobia demonstrate a much 
higher occurrence in females (6-7%) than in males 
(1.8-3.1%; Kirkpatrick & Berg, 1981; van Hout & 
Bouman, 2012). Those with emetophobia symptoms 
have severe, negative impairments in quality of life and 
may develop co-occurring anxiety disorders (e.g., gen-
eralized anxiety disorder (GAD), obsessive-compul-
sive disorder (OCD), social anxiety disorder (SAD); 
Boschen, 2007; Keyes et al., 2017). 
 In addition to the core symptom of pervasive fear 
of vomiting, there are a variety of fear emphases that 
an individual may also hold. For example, 41-75% of 
individuals with emetophobia present with a primary 
fear of vomiting themselves; while 18-45% of individ-
uals are primarily debilitated upon seeing others vomit 
in their presence (Keyes & Veale, 2018). Other fears of 
vomiting surround the potential of choking on vom-

it leading subsequent to death, the act of vomiting in 
public (16-62%), and/or the physiological symptoms 
themselves associated with vomiting (Keyes & Veale, 
2018). These impairing symptoms of emetophobia 
are supported through elaborate safety-seeking and 
avoidance behaviors, such as checking food expiration 
dates and avoiding contact with an ill person (Simons 
& Vloet, 2018; van Hout & Bouman, 2012). Through 
these consistent responses with acute reinforcement, 

the phobia is actively maintained and exacerbated.
 Though symptoms overlap, it is evident that anx-
iety and fear are both unique constructs and com-
ponents observed in anxiety disorders (Gullone et 
al., 2000; McNaughton & Corr, 2008; Perkins et al., 
2007; Woody & Teachman, 2000). The psychological 
constructs of anxiety and fear have been conceptual-
ized using the revised Reinforcement Sensitivity Theo-
ry (r-RST), a neuropsychological model of personality 
and motivation developed by Gray and McNaughton 
(2000). The r-RST consists of three motivational 
systems that work together to respond to threats: be-
havioral activation and inhibition systems (BIS and 
BAS) and the fight, flight, freeze system (FFFS; Corr 
& Krupić, 2017; McNaughton & Corr, 2008). The 
BIS and BAS are predominantly used to conceptualize 
anxiety, which is posited to occur upon approaching 
of perceived danger (Gray & McNaughton, 2000; 



88

McNaughton & Corr, 2008). The third motivational 
system, the FFFS, is used to operationalize the temper-
ament of fear, which operates upon active avoidance 
(i.e., leaving the vicinity) of perceived danger (Gray 
& McNaughton, 2000; McNaughton & Corr, 2008; 
Walker & Jackson, 2017). Indeed, the BIS and BAS, 
and to a lesser extent the FFFS (Kimbrel et al., 2008), 
have been used in the conceptualization of anxiety 
symptoms and disorders (e.g., SAD and OCD; Bijtte-
bier et al., 2009; Katz et al., 2020). One area of lim-
ited research is the relationship of FFFS with anxiety 
disorders (Kambouropoulos et al., 2014; Kimbrel et 
al., 2008). As the r-RST motivational symptoms are 
concurrently activated (Corr & Krupić, 2017; Mc-
Naughton & Corr, 2008), it stands to reason that the 
temperament of fear, as operationalized by the FFFS, is 
implicated in the experience of anxiety symptoms, and 
likely emetophobia symptoms.
 The FFFS is maintained through learned avoid-
ance of aversive stimuli and is theorized to be highly 
sensitive to punishment (Kimbrel et al., 2008), thereby 
reinforcing avoidance behaviors seen in anxiety disor-
ders and likely emetophobia. Specifically, the fight re-
sponse is characterized by defensive aggression evoked 
in the presence of proximal, unescapable threats; while 
the flight response is conceptualized as a quick, direct 
escape from distal threats (Walker et al., 2017). Finally, 
the freeze response is considered a physiological panic 
response to distal threats involving physical immobili-
ty (Walker et al., 2017). Although the flight and freeze 
responses are classic avoidance behaviors seen in eme-
tophobic responses to potential or distal fear (e.g., leav-
ing the vicinity of an ill individual or shutting down 
mentally and physically upon the sight of vomit; Keyes 
et al., 2017, Veale et al., 2013), the fight response may 
also occur. For example, a threatening situation (e.g., 
the inability to vacate a room with ill colleagues) may 
provoke a fight response expressed as outright physical 
or verbal aggression or subtle nonverbal hostility. As 
is consistently demonstrated in phobic disorders, rein-
forcement and behavioral responses have a significant 
effect on the presentation and severity of emetophobia 
(Keyes & Veale, 2018; Wu et al., 2015). 

The Present Study
 To date, the symptoms of emetophobia have not 
been assessed within the r-RST framework or the spe-
cific FFFS motivational system. The primary aim of 

the present exploratory study was to assess the overall 
relationship between emetophobia symptoms, general 
symptoms of anxiety, and fight, flight, freeze tenden-
cies (combined and individually) in an undergraduate, 
analog population. As fear is inherently involved in 
phobias and other anxiety disorders, the current study 
aimed to examine both symptoms of emetophobia 
and overall anxiety with the FFFS motivation system. 
Based on the r-RST theory and current conceptualiza-
tion of emetophobia, it was hypothesized that emeto-
phobia symptoms, general anxiety, and FFFS would 
be positively associated. A secondary aim of the study 
was to investigate the unique contribution of fear in 
the experience of emetophobia symptoms when con-
trolling for the known association of general anxiety 
symptoms (Boschen, 2007). 

Methods
Participants and Procedures 
 Participants (N = 186; Mage = 19.05 years, SD = 
1.69) were undergraduate students, aged 18 to 36 years 
old, enrolled in an introductory Psychology course at 
a large South-Eastern university in the United States. 
Participants were recruited via class announcements 
and through SONA Systems (an online participant 
recruitment portal). No other inclusion or exclusion 
criteria were present as this was an exploratory study 
assessing potential associations between temperamen-
tal fear and symptoms of emetophobia in an analog 
sample. Further, symptoms of emetophobia may de-
velop after the average age of onset and often persist 
through adulthood (Keyes et al., 2017), the current 
sample of undergraduate students is consistent with 
individuals with emetophobia who may seek treat-
ment for persistent symptoms. The majority of par-
ticipants were female (74.9%; 25.1% male) and White 
(71.7%), though participants also identified as African 
American (21.2%), Asian (1.6%), Native American 
or Alaskan Native (0.5%), or Multiracial (4.6%), and 
5.2% identified as Hispanic. 
 As a part of a larger study, undergraduate students 
presented in person to the lab. Prior to study com-
mencement participants provided verbal and written 
informed consent, and then completed a series of 
self-report questionnaires (non-randomized). Partici-
pants received research course credit for participation. 
The following three questionnaires were examined for 
the purposes of the current study. All procedures were 

PETELL, WICKENHAUSER, MAACK



89

approved by the University’s Institutional Review 
Board. 
Instruments 
 The Specific Phobia of Vomiting Inventory 
(SPOVI; Veale, et al., 2013). The SPOVI is a short, 14-
item measure assessing fear of vomiting symptoms ex-
perienced within the last seven days. All items are rated 
on a Likert-type scale from 0 (symptoms not at all ex-
perienced) to 4 (symptoms experienced all the time). 
Scores are summed, with higher scores suggesting an 
increased experience of SPOV symptoms (range 0-35). 
A clinical cut-off of 10 has been previously proposed 
(Veale, et al., 2013), which was endorsed by 9.14% of 
the current study sample (n = 17). The SPOVI has 
displayed good internal consistency (α = .89), good 
convergent and divergent validity in college samples, 
and has evidenced invariance across sex (Maack et al., 
2017). In the current study, the SPOVI also demon-
strated good internal consistency (α = .82).  
 The Fight, Flight, Freeze Questionnaire (FFFQ; 
Maack et al., 2015). The FFFQ is a 21-item measure as-
sessing the typical reaction of an individual to a threat-
ening situation. All items are rated on a Likert-type 
scale from 1 (experienced almost never) to 5 (experi-
enced almost always). The measure results in a total 
FFFQ score as well as three subscale scores individu-
ally assessing fight, flight, and freeze. The FFFQ has 
demonstrated reliable internal consistency overall (α = 
.92) and with all subscale scores (fight: α = .91; flight: 
α = .94; freeze: α = .86; Maack et al., 2015; Walker & 
Jackson, 2017). The current study found similarly 
good internal consistency for the overall FFFQ score 
(α = .93) and individual subscales (fight: α = .90; flight: 
α = .94; freeze: α = .91).
 The Depression, Anxiety, Stress Scale (DASS-
21; Lovibond & Lovibond, 1995). The DASS-21 as-
sesses depression, anxiety, and stress symptoms experi-
enced within the last week, consisting of 21 items. All 
items are on a Likert-type scale from 0 (not applicable) 
to 3 (applicable much of the time). The 7-item anxiety 
subscale was used to assess anxiety as a potential covari-
ate apart from overall temperamental fear. Both the 
overall scale and anxiety subscale scores have demon-
strated good internal consistency (α = .82 and α = .81, 
respectively; Crawford & Henry, 2003; Osman et al., 
2012). The current study showed acceptable internal 
consistency for the subscale of interest (anxiety sub-
scale: α = .71) and overall scale (α = .74). 

Statistical Analysis
 All data analyses were conducted using SPSS ver-
sion 27. Data was cleaned prior to analyses. Of the orig-
inal sample (N= 194), three participants were removed 
for missing more than 10% of data, five multivariate 
outliers were removed using Mahalanobis distance, 
and additional missing data was replaced with vari-
able means. Preliminary analyses of the final sample 
(N= 186) included descriptive statistics and zero-or-
der correlations for all variables of interest. Following 
this, a hierarchical regression analysis was run to assess 
the unique variance of predictors on the experience of 
emetophobia symptoms. Post-hoc analyses, including 
correlations, independent samples t-tests, and a mod-
eration analysis, examined the potential impact and 
interactional effects of sex on the relationship between 
temperamental fear and emetophobia symptoms.

Results
Descriptive statistics and intercorrelations among vari-
ables of interest are presented in Table 1. As illustrated, 
SPOV symptoms were significantly related to anxiety 
(r = .20, p < .01) and both the overall temperament of 
fear (r = .17, p < .05) and the fight subscale (r = .15, p 
< .05). However, the subscales of freeze (r = .13, p = 
.08) and flight (r = .13, p = .08) were not significantly 
associated with SPOV symptoms. 
To assess the unique contribution of the temperamen-
tal fear response to the experience of emetophobia 
symptoms, distinct from general anxiety symptoms, 
a hierarchical regression analysis was run with SPOV 
symptoms as the dependent variable (see Table 2). In 
the first step of the model, the fight subscale (the only 
significantly associated subscale of fear) was entered. 
This step of the model was significant (F[1, 184] = 
4.03, p < .05, ΔR2 = .02), with fight accounting for 
2.1% of the variance in the prediction of emetophobia 
symptoms. Next, in the second step of the model, anx-
iety was added. The overall model was significant (F[1, 
183] = 5.72, p < .01, ΔR2 = .03); however, the contri-
bution of the fight subscale no longer added unique 
predictive ability. 

Post-hoc Analyses
 Given the above unexpected findings and clear sex 
differences in the occurrence of emetophobia symp-
toms evidenced in previous studies (Kirkpatrick & 

  FEAR TENDENCIES AND EMETOPHOBIA SYMPTOMS



90

Berg, 1981; van Hout & Bouman, 2012), post-hoc 
analyses related to sex were conducted to elucidate 
potential unique contributions of sex in the present 
preliminary study. Additionally, although using a 
non-clinical sample for an initial exploratory study, an 
assessment of clinical elevations of SPOV symptoms 
occurred. In the current study, 17 participants (9.14%) 
met or exceeded the threshold for clinical cut-off scores 
on the SPOVI (score > 10). Consistent with the pre-
viously mentioned studies (Kirkpatrick & Berg, 1981; 
van Hout & Bouman, 2012), of the 17 participants 
who met the SPOVI clinical cut-off, 13 were females 
(6.99%), while only 4 were males (2.27%). Point-biseri-
al correlations demonstrated that sex was only signifi-
cantly associated with the flight subscale (r = .17, p < 
.05) and was not significantly associated with SPOV 
symptoms, anxiety, overall temperamental fear, or the 
fight or freeze subscales. Further, independent samples 
t-tests demonstrated no significant differences between 
sex among any of the variables (ps > .05).
 A simple moderation analysis using PROCESS 
3.5 by Hayes (Hayes, 2018) was conducted to test if 
sex acted as a moderator among temperamental fear 
and emetophobia symptoms. Temperamental fear was 
entered as the predictor variable, sex as the moderator, 
and SPOV symptoms as the outcome. Anxiety was en-
tered as a covariate. The overall model was significant 
(F [4, 178] = 3.66, p < .01, R2 = .08). More important-
ly, the interaction between temperamental fear and 
sex was also significant (F [1, 178] = 4.14, p < .05, R2 
= .02). Specifically, the relationship between temper-
amental fear and SPOV symptoms was significantly 
stronger for men compared to women (see Figure 1).

Discussion
 The aim of the current study was to investigate 
the fight, flight, freeze motivational system and its rela-
tions with symptoms of emetophobia. Results provid-
ed initial evidence for the impact of fear, specifically 
the fight tendency, on symptoms of the specific phobia 
of vomiting. However, further extrication of fear and 
anxiety is needed.
 Consistent with theory and as hypothesized, the 
overall temperament of fear was found to be signifi-
cantly associated with symptoms of emetophobia 
(Harnett et al., 2013; Keyes & Veale, 2018; Perkins 
et al., 2007; Wu et al., 2015). However, contrary to 
the hypotheses, not all domains of the FFFS behav-

ioral responses were related. Specifically, the flight 
and freeze responses, common reactions to potential 
threats across species (Roelofs, 2017), were not sig-
nificantly associated with emetophobia symptoms in 
the current study. Notably, the fight response was the 
only fear domain significantly associated with SPOV 
symptoms. Regarding the salient role of the fight re-
sponse in the overall sample, individuals may respond 
differently in situations wherein active avoidance (i.e., 
escape from the immediate and proximal threat) of 
vomit is not available (McNaughton & Corr, 2008). 
The perceived urgency of threat and inaccessible es-
cape in these situations may prompt the fight response 
to override other FFFS reactions experienced more 
commonly among distal threats. However, upon fur-
ther examination, the fight subscale did not add sig-
nificant predictive utility above and beyond general 
anxiety symptoms. Additional research may examine 
the unique impact of the remaining motivational sys-
tems of the r-RST, the BIS and BAS, which are oper-
ationalized as the anxiety response (McNaughton & 
Corr, 2008), and provide a further understanding of 
these results. It is possible that SPOV symptoms are 
more closely linked to a preparatory response in an-
ticipation of future negative consequences from the 
act of vomiting as opposed to a defensive response 
to vomiting alone (Barlow, 2002; Lang et al., 2000). 
 Potential explanations for the aforementioned 
discrepancies observed in the FFFS and emetophobia 
symptoms may involve documented hypervigilance 
regarding perceived vomit-related risks and threats 
(Boschen, 2007; Keyes & Veale, 2018). The flight and 
freeze responses are implicated in response to perceived 
threats that are distal to the individual, while the fight 
response uniquely combats proximal threats (Walk-
er et al., 2017). Given the significant association of 
emetophobia symptoms with the fight response, this 
suggests participants in the current study perceived 
a proximal, immediate threat wherein active avoid-
ance was unattainable (McNaughton & Corr, 2008). 
However, this perception may have been overshad-
owed by the strong connection between emetophobia 
symptoms and general anxiety about potential future 
threats that could result from vomiting (e.g., difficulty 
breathing, choking, embarrassment). Further research 
may benefit by clarifying the situational contexts 
unique to emetophobia which provoke the perception 
of proximal and distal threats and consequent arousal.

PETELL, WICKENHAUSER, MAACK



91

 In addition to being impacted by assessed distance 
(i.e., proximal or distal) from threat (i.e., vomiting), sex 
differences have also been demonstrated to impact risk 
perception across species (Gruene et al., 2015; Gus-
tafsod, 1998; Jones & Monfils, 2016). In the current 
study, the flight response was associated with being fe-
male, which suggests differential behavioral responses 
in the motivational system may occur. One possibility 
is that females may achieve more successful attempts 
of physically or mentally distancing from vomit. For 
instance, females experiencing emetophobia may em-
ploy flight responses (such as actively avoiding ill chil-
dren at the local preschool or temporarily restricting 
food consumption) to avoid possible situations of 
vomit that may or may not occur in the distal future. 
Additional research should examine the frequency of 
the specific motivational systems of the r-RST among 
males and females, and whether those systems were 
successful at avoiding the anxiety-provoking stimuli.
 Negative affect, including experience of anger and 
irritability, may also account for differences in behav-
ioral responses. Emotions of negative affect (anger or 
irritability, anxiety, disgust, etc.) are expressed among 
various emotional disorders, such as anxiety and de-
pression (Hofmann et al., 2012; Hundt et al., 2013) 
and have been linked to higher intensity in women 
(Fujita et al., 1991). Within the revised Reinforcement 
Sensitivity Theory (r-RST), the experience of negative 
affect has also been demonstrated to negatively impact 
the perception of daily events (Hundt et al., 2013). 
Further, the specific emotion of anger has been posi-
tively associated with heightened sensitivity to reward 
and aggression, and it is further associated with an ele-
vated fight response to threatening situations (Hundt 
et al., 2013; Roelofs, 2017). As such, the fight response 
may be perceived as resulting in a larger, more salient 
reward (to evade the proximal, immediate threat) than 
flight or freeze (to evade the distal, potential threat). 
Thus, negative affect, particularly when account-
ing for sex differences, may alter the behavioral re-
sponse of the FFFS in individuals with emetophobia. 
 Given the inconsistencies between the current 
study’s findings and theory, post-hoc analyses were 
conducted to explore a potential missing link of the 
previous analyses: sex. Results from the current study 
demonstrated clinical levels of emetophobia symp-
toms were three times more prevalent in female par-
ticipants than males, consistent with prior research 

(Kirkpatrick & Berg, 1981; van Hout & Bouman, 
2012). Interestingly, the significant interaction effect 
found in the moderation model demonstrated a stron-
ger relation among men for temperamental fear and 
emetophobia symptoms. That is, during moments 
wherein heightened fear symptoms are activated, men 
will likely experience increased severity of emetophobia 
symptoms. In comparison, this effect was not found 
in females in the current sample. Elucidating wheth-
er this demonstration is unique to the FFFS, as com-
pared to the BIS and BAS, may provide further un-
derstanding regarding sex differences in emetophobia.
 It is possible, potentially as a result of societal dif-
ferences and behavioral expectations among sex, that 
males and females may display and engage in emeto-
phobia symptoms differently. Sex differences have 
been evidenced across the lifespan among tempera-
mental fear and anxiety symptoms (McLean & An-
derson, 2009). For example, disgust sensitivity, or the 
degree an individual regulates the emotion of disgust, 
has been found to be higher in females than in males 
(Cisler et al., 2009; Connolly et al., 2008). As disgust 
sensitivity promotes avoidance of perceived disease 
(Connolly et al., 2008), this suggests females may en-
gage in increased flight responses, as evidenced in the 
current study. Future studies are needed to elucidate 
sex differences in the experience of emetophobia to 
provide additional contextual information to better 
inform treatment approaches. Overall, the results of 
the current preliminary study add to the current con-
ceptualization of emetophobia as its relationship with 
the temperament of fear combined with the impact 
of sex has not yet been documented in the literature.

Limitations 
 Although this preliminary study of temperamental 
fear and symptoms of emetophobia furthers the extant 
literature, it is not without limitations. Specifically, 
data was collected from an undergraduate population 
with no formal diagnostic assessment of emetophobia 
or other psychiatric disorders. As the study was con-
sidered exploratory to first determine the potential of 
a relation between fear tendencies and symptoms of 
emetophobia, there were no exclusion or inclusion cri-
teria. It is important to note that substantial variance 
nical sample although having good internal validity (α 
= .82 in this sample) may not be representative of exter-
nal validity (i.e., true diagnostic status). Moreover, rep-

  FEAR TENDENCIES AND EMETOPHOBIA SYMPTOMS



92

licating this study in a clinical sample with structured 
clinical assessments of emetophobia is needed to truly 
further the overall conceptualization of emetophobia.
 Another limitation, as previously mentioned, 
was that the study relied upon self-report measures 
wherein the threat of immediate and proximal vom-
it was not present, thereby potentially impacting 
the innate behavioral responses of participants. 
Despite these limitations, the current study pro-
vides a novel, initial understanding of the FFFS 
and the impact of sex on emetophobia symptoms. 
 To address such limitations in the future, studies 
employing behavioral avoidance tasks (BATs) relat-
ed to emetophobia stimuli may improve the under-
standing of natural behavioral responses across sex 
and in response to tangible vomit-specific threats. 
Additionally, research examining the FFFS in indi-
viduals formally diagnosed with emetophobia may 
contribute to a comprehensive conceptualization of 
this disorder. Additionally, clarity on possible con-
founding variables related to FFFS presentation may 
be provided by formal diagnostic assessment by a 
trained clinician and/or the addition of self-report 
measures. Finally, based on previous literature indicat-
ing anger is associated with an increased sensitivity to 
reward, the emotion of anger in relation to the over-
all temperament of fear, individual response tenden-
cies (i.e. fight, flight, freeze), and symptoms of eme-
tophobia is worth exploration (Hundt et al., 2013).
 
Conclusion
 The present study assessed the associations of 
temperamental fear (fight, flight freeze systems) with 
the experience of emetophobia symptoms. Although 
symptoms of emetophobia were associated with the 
temperament of fear, specifically the fight subscale, 
none of the subscales offered predictive utility above 
and beyond general anxiety symptoms. Interestingly, 
post-hoc analyses revealed that sex moderated the re-
lationship between the overall FFFS and emetophobia 
symptoms, such that this relationship was much stron-
ger for male participants than for females. To advance 
the conceptualization of emetophobia, additional 
research is needed to first confirm the association be-
tween the FFFS and emetophobia behaviors (i.e. using 
behavioral tasks) and then assess/identify these specific 
fear behaviors in a clinical sample. Further, exploring 
whether the temperament of fear is generalized to vom-

it-specific stimuli and proximally threatening situations 
may provide information to assist with comprehensive 
treatment. Importantly, the current study expands the 
literature in the area of emetophobia by assessing the 
specific underlying temperamental vulnerability of 
fear, the impact of sex, and how this relationship sig-
nificantly affects symptoms of this phobic experience.

References
Barlow, D. H. (2002). Anxiety and its disorders: The 

nature and treatment of anxiety and panic (2nd 
ed.). New York, NY: Guilford Press.

Bijttebier, P., Beck, I., Claes, L., & Vandereycken, W. 
(2009). Gray’s Reinforcement Sensitivity Theory 
as a framework for research on personality–psy-
chopathology associations. Clinical Psychology 
Review, 29(5), 421–430. https:// doi:10.1016/j.
cpr.2009.04.002.

Boschen, M. J. (2007). Reconceptualizing emeto-
phobia: A cognitive–behavioral formulation and 
research agenda. Journal of Anxiety Disorders, 
21(3), 407-419. https://doi.org/10.1016/j.janx-
dis.2006.06.007

Cisler, J. M., Olatunji, B. O., & Lohr, J. M. (2009). 
Disgust sensitivity and emotion regulation po-
tentiate the effect of disgust propensity on spider 
fear, blood-injection-injury fear, and contami-
nation fear. Journal of Behavior Therapy and Ex-
perimental Psychiatry, 40(2), 219–229. https://
doi:10.1016/j.jbtep.2008.10.002

Connolly, K. M., Olatunji, B. O., & Lohr, J. M. 
(2008). Evidence for disgust sensitivity mediating 
the sex differences found in blood-injection-in-
jury phobia and spider phobia. Personality and 
Individual Differences, 44(4), 898–908. https://
doi:10.1016/j.paid.2007.10.020

Crawford, J. R., & Henry, J. D. (2003). The Depres-
sion Anxiety Stress Scales (DASS): Normative data 
and latent structure in a large non-clinical sample. 
British Journal of Clinical Psychology, 42, 111–
131. https:// doi:10.1348/014466503321903544

Fujita, F., Diener, E., & Sandvik, E. (1991). Gender dif-
ferences in negative affect and well-being: The case 
for emotional intensity. Journal of Personality and 
Social Psychology, 61(3), 427–434. https://doi-org.
umiss.idm.oclc.org/10.1037/0022-3514.61.3.427

Gray, J.A., & McNaughton, N. (2000). The neuro-
psychology of anxiety. Oxford: Oxford University 

PETELL, WICKENHAUSER, MAACK



93

Press.
Gruene, T. M., Flick, K., Stefano, A., Shea, S. D., & 

Shansky, R. M. (2015). Sexually divergent ex-
pression of active and passive conditioned fear 
responses in rats. Elife, 4, e11352. https://doi: 
10.7554/eLife.11352

Gullone, E., King, N. J., & Ollendick, T. H. (2000). 
The development and psychometric evalua-
tion of the Fear Experiences Questionnaire: 
An attempt to disentangle the fear and anx-
iety constructs. Clinical Psychology & Psy-
chotherapy, 7(1), 61-75. https://doi:10.1002/
(SICI)1099-0879(200002)7:1<61::AID-CP-
P227>3.0.CO;2-P

Gustafsod, P. E. (1998). Gender Differences in risk 
perception: Theoretical and methodological per-
spectives. Risk analysis, 18(6), 805-811. https://
doi.org/10.1023/B:RIAN.0000005926.03250.c0

Harnett, P. H., Loxton, N. J., & Jackson, C. J. (2013). 
Revised reinforcement sensitivity theory: Im-
plications for psychopathology and psycholog-
ical health. Personality and Individual Differ-
ences, 54(3), 432–437. https://doi:10.1016/j.
paid.2012.10.019

Hayes, A. F. (2018). Introduction to mediation, mod-
eration, and conditional process analysis: A regres-
sion-based approach (2nd edition). Guilford Press.

Hofmann, S. G., Sawyer, A. T., Fang, A., & Asnaani, 
A. (2012). Emotion dysregulation model of mood 
and anxiety disorders. Depression and anxiety, 
29(5), 409-416. https:// doi:10.1002/da.21888

Hundt, N. E., Brown, L. H., Kimbrel, N. A., Walsh, 
M. A., Nelson-Gray, R., & Kwapil, T. R. (2013). 
Reinforcement sensitivity theory predicts positive 
and negative affect in daily life. Personality and 
Individual Differences, 54(3), 350–354. https://
doi:10.1016/j.paid.2012.09.021

Jones, C. E., & Monfils, M.-H. (2016). Fight, flight, or 
freeze? The answer may depend on your sex. Trends 
in Neurosciences, 39(2), 51–53. https://doi-org.
umiss.idm.oclc.org/10.1016/j.tins.2015.12.010

Kambouropoulos, N., Egan, S., O’Connor, E. J., & 
Staiger, P. K. (2014). Escaping threat: Understand-
ing the importance of threat sensitivity in social 
anxiety. Journal of Individual Differences, 35(1), 
47.https://doi: 10.1027/1614-0001/a000126

Keyes, A., Gilpin, H. R., & Veale, D. (2017). Phe-
nomenology, epidemiology, co-morbidity and 

treatment of a specific phobia of vomiting: A 
systematic review of an understudied disorder. 
Clinical Psychology Review, 60, 15-31. https:// 
doi:10.1016/j.cpr.2017.12.002

Keyes, A., & Veale, D. (2018). Atypical eating disor-
ders and specific phobia of vomiting: Clinical 
presentation and treatment approaches. In L. K. 
Anderson, S. B. Murray, W. H. Kaye, L. K. An-
derson, S. B. Murray, W. H. Kaye (Eds.), Clinical 
handbook of complex and atypical eating disor-
ders (pp. 270-289). New York, NY, US: Oxford 
University Press.

Kimbrel, N. A., Cobb, A. R., Mitchell, J. T., Hundt, 
N. E., & Nelson-Gray, R. O. (2008). Sensitivity 
to punishment and low maternal care account 
for the link between bulimic and social anxiety 
symptomology. Eating Behaviors, 9(2), 210–217.  
https:// doi:10.1016/j.eatbeh.2007.09.005

Kirkpatrick, D. R., & Berg, A. J. (1981). Fears of a het-
erogeneous, nonpsychiatric sample: A factor an-
alytic study. Paper presented at the Am. psychol. 
Ass. Conf. Los Angeles, Calif.

Corr, P. J., & Krupić, D. (2017). Motivating personal-
ity: Approach, avoidance, and their conflict. In A. 
J. Elliot (Ed.), Advances in motivation science (pp. 
39–90). Elsevier Academic Press.

Katz, B. A., Matanky, K., Aviram, G., & Yovel, I. 
(2020). Reinforcement sensitivity, depression 
and anxiety: A meta-analysis and meta-analytic 
structural equation model. Clinical Psychology 
Review, 77, 101842. https://doi.org/10.1016/j.
cpr.2020.101842

Lang, P. J., Davis, M., & Ohman, A. (2000). Fear and 
anxiety: Animal models and human cognitive 
psychophysiology. Journal of Affective Disorders, 
61(3), 137-159. https://doi.org/10.1016/s0165-
0327(00)00343-8

Lipsitz, J. D., Fyer, A. J., Paterniti, A., & Klein, D. F. 
(2001). Emetophobia: Preliminary results of an 
Internet survey. Depression and Anxiety, 14(2), 
149-152. https://doi:10.1002/da.1058

Lovibond, S.H. & Lovibond, P.F. (1995). Manual for 
the Depression Anxiety & Stress Scales. (2nd Ed.) 
Sydney: Psychology Foundation.

Maack D.J., Ebesutani C, Smitherman T.A. (2017) 
Psychometric investigation of the specific pho-
bia of vomiting inventory: A new factor model. 
International Journal of Methods in Psychiatry 

  FEAR TENDENCIES AND EMETOPHOBIA SYMPTOMS



94

Research, 27(1), e1574. https://doi.org/10.1002/
mpr.1574

Maack, D. J., Buchanan, E., & Young, J. (2015). De-
velopment and psychometric investigation of an 
inventory to assess fight, flight, and freeze tenden 
cies: the fight, flight, freeze questionnaire. Cogni-
tive Behavior Therapy, 44(2), 117-127. https:// do
i:10.1080/16506073.2014.972443

McLean, C. P., & Anderson, E. R. (2009). Brave men 
and timid women? A review of the gender differ-
ences in fear and anxiety. Clinical Psychology Re-
view, 29(6), 496–505. https://doi-org.umiss.idm.
oclc.org/10.1016/j.cpr.2009.05.003

McNaughton, N., & Corr, P. J. (2008). The neuropsy-
chology of fear and anxiety: A foundation for Re-
inforcement Sensitivity Theory. In P. J. Corr (Ed.), 
The reinforcement sensitivity theory of person-
ality. (pp. 44–94). Cambridge University Press. 
https://doi-org.umiss.idm.oclc.org/10.1017/
CBO9780511819384.003

Osman, A., Wong, J. L., Bagge, C. L., Freedenthal, 
S., Gutierrez, P. M., & Lozano, G. (2012). The 
Depression Anxiety Stress Scales—21 (DASS-
21): Further examination of dimensions, scale 
reliability, and correlates. Journal of Clinical Psy-
chology, 68(12), 1322–1338. https://doi:10.1002/
jclp.21908

Perkins, A. M., Kemp, S. E., & Corr, P. J. (2007). Fear 
and anxiety as separable emotions: An investiga-
tion of the revised reinforcement sensitivity theo-
ry of personality. Emotion, 7(2), 252–261. https://
doi:10.1037/1528-3542.7.2.252

Roelofs, K. (2017). Freeze for action: Neurobiolog-
ical mechanisms in animal and human freezing. 
Philosophical Transactions of the Royal Society: 
Biological Sciences, 372(1718), 20160206. https:// 
doi:10.1098/rstb.2016.0206

Simons, M., & Vloet, T. D. (2018). Emetophobia—A 
metacognitive therapeutic approach for an over-
looked disorder. Zeitschrift Für Kinder- Und Ju-
gendpsychiatrie Und Psychotherapie, 46(1), 57-66. 
https:// doi:10.1024/1422-4917/a000464

Van Hout, W. J., & Bouman, T. K. (2012). Clinical 
features, prevalence and psychiatric complaints 
in subjects with fear of vomiting. Clinical Psy-
chology & Psychotherapy, 19(6), 531-539. https:// 
doi:10.1002/cpp.761

Veale, David & Hennig, Camilla & Gledhill, Lucinda. 

(2015). Is a specific phobia of vomiting part of the 
obsessive compulsive and related disorders? Jour-
nal of Obsessive-Compulsive and Related Disorders, 
7, 1-6. https://doi: 10.1016/j.jocrd.2015.08.002.

Veale, D., Ellison, N., Boschen, M. J., Costa, A., Whel-
an, C., Muccio, F., & Henry, K. (2013). Develop-
ment of an inventory to measure specific phobia of 
vomiting (emetophobia). Cognitive Therapy and 
Research, 37(3), 595-604. https:// doi:10.1007/
s10608-012-9495-y

Walker, B. R., & Jackson, C. J. (2017). Examining 
the validity of the revised Reinforcement Sensi-
tivity Theory scales. Personality and Individual 
Differences, 106, 90-94. https:// doi:10.1016/j.
paid.2016.10.035

Walker, B. R., Jackson, C. J., & Frost, R. (2017). A com-
parison of revised reinforcement sensitivity theory 
with other contemporary personality models. Per-
sonality and Individual Differences, 109232-236. 
https://doi:10.1016/j.paid.2016.12.053

Woody, S. R., & Teachman, B. A. (2000). Intersection 
of disgust and fear: Normative and pathological 
views. Clinical Psychology: Science and Practice, 
7(3), 291-311. https://doi:10.1093/clipsy/7.3.291

Wu, M. S., Rudy, B. M., Arnold, E. B., & Storch, E. 
A. (2015). Phenomenology, clinical correlates, 
and impairment in emetophobia. Journal of Cog-
nitive Psychotherapy, 29(4), 356-368. https://
doi:10.1891/0889-8391.29.4.356

 

PETELL, WICKENHAUSER, MAACK



95

  FEAR TENDENCIES AND EMETOPHOBIA SYMPTOMS



96

PETELL, WICKENHAUSER, MAACK



97

  FEAR TENDENCIES AND EMETOPHOBIA SYMPTOMS


