Pseudodysphagia Phobia (Phagophobia): An Uncommon Pseudo-Dysphagia Phobic Disorder, Treated with CBH (Cognitive Behavioural Hypnotherapy): A Case Report.
By Dr. Anand Chandrasegaran
We present a case of a 28-year-old female, who presented with a diagnosis of pseudo-dysphagia and choking phobia for 7 years. She was managed with the Cognitive Behavioural Hypnotherapy (CBH) strategy. Pseudo-dysphagia is the unjustified fear of swallowing causing a choking-like feeling. The act of swallowing becomes mentally linked with choking. This patient was experiencing features of phagophobia and she developed unhealthy coping ways. The root of her psychosomatic disorder was poorly managed anxiety. The patient was managed with CBH which involved 3 approaches, cognitive restructuring, systematic exposure, and mindfulness training. Each step was preceded by formal hypnosis or conversational hypnosis processes. There is adequate evidence pointing to treatment protocol consisting of psycho-education, cognitive restructuring, aversion /distraction and in-vivo exposure that had resulted in remission of symptoms in patients with choking phobia. She retained therapeutic benefits following this treatment protocol. The index case highlights that clinicians should be aware of this disorder and that CBH can be considered for psychogenic dysphagia.
Key Words: Phagophobia, Hypnosis, dysphagia, anxiety, cognitive behavioural therapy, Psychogenic dysphagia
We present a case of a 28-year-old female who presented with a diagnosis of pseudo-dysphagia and has been having choking phobia for 7 years. She was managed with Cognitive Behavioural Hypnotherapy method (utilisation of cognitive behavioural therapy under hypnosis).
Pseudo-dysphagia is a diagnosis of exclusion. For patients suffering from this, the sensation of choking is as absolute as there is a pathological or physiological obstruction in the oesophagus. This can lead to panic reactions before or during the act of swallowing.
Choking phobia (phagophobia) which stems from pseudo-dysphagia is a comparatively uncommon phobic disorder which some otorhinolaryngologists and clinicians feel frustrated in managing this psychogenic dysphagia. This unique presentation can have significant effects on the physical and psychological health of an individual.
Phagophobia is interpreted as an unusual condition represented by an excessive fear of choking followed by avoidance of swallowing solid food or liquids in the lack of anatomical or physiological anomalies (Lopes R, 2014).
Patients generally present with an account of intense anxiety brought about by eating food or drinks after an awful experience but it may still be seen without such an experience (McNally RJ, 1994). Fear of choking appears to develop more repeatedly in females than in males and has a variable age of onset varying from childhood to old age. Its prevalence is unknown and appears responsive to anxiolytic medication and to cognitive and behavioral therapies (Richard, 1994).
In routine clinical practises, it is not unusual for otorhinolaryngologists or any clinicians to treat a pseudo-dysphagia patient. Several treatment strategies have been adopted, but there is no shared consensus over an appropriate approach.
Medical Hypnosis is a technique that can be utilised with success in most cases of psychosomatic illness (Maher-Loughnan, 1980a).
Miss Y, a 28 years old school educator showed up at the author’s clinic in pursuit of intervention for her psychosomatic presentation. She has sought various therapeutic interventions for the past 7 years, but her anxiety and the choking sensation as she eats were getting worse. Her doctors encouraged her to pursue counselling help to deal with her anxiety. She has been going for 10 counselling sessions, which does help her to understand her emotions better, but has not resolved her intense anxiety with regard to swallowing. This patient was referred to the author’s clinic for hypnotherapy assistants hoping to find a solution to her phagophobia symptom.
Further examination of the patient’s clinical history disclosed that her phagophobia started when she was 16 years old when her mother was diagnosed with hepatitis C infection. At the initial stage, she was merely having anxiety issues. She was afraid that her mother would go into a liver failure state (as that’s the natural evolution of Hepatitis C liver disease). This fear constantly caused her to worry. After 5 years of that diagnosis, her mother was diagnosed to have liver carcinoma secondary to the advancement of Hepatitis C. Upon receiving this news, the patient claimed she was prepared for the bad news and took the news rather well. However, she was aware that, her anxiety symptoms appeared to worsen especially when she eats. By this time, she was already 21 years old. Every time she swallows, she feels the food gets stuck in her throat and gave her a choking sensation. First few months of having this sudden choking feeling, her friends and family would rush her to the hospital emergency unit. By then her symptoms would have been settled. However, the next day, she would experience the same sensations. An upper gastroscopy was done and an assessment from an ENT consultant was reported as all normal findings, with no obvious pathological lesion noted.
The patient was still experiencing features of phagophobia and to cope with this, the patient developed her own coping experiences. She would eat small food fragments and consume plenty of water to ward off the sensation of choking. Due to this, she was not able to eat an adequate amount of food and this persisted for almost 5 years. Every year, she would have an upper gastroscopy and ENT assessment, as she still feels the choking sensations. However, every year, the results show normal findings. At this stage, the vicious cycle of swallowing leading to the choking sensation created depressive-like manifestations in her. The patient started having social uneasiness, dreading others knowing she has this problem.
She was obsessed with her fear related to swallowing and paid less attention to her school performance as an educator. Due to this, the appraisal by her school management dropped and this further made her worried. She started to display depressive symptoms such as persistent grief, anhedonia, feeling helpless, perceptions of worthlessness and poor self-esteem. There was no account of any suicidal ideations, delusions or hallucinations or any history of fear of any other specific object or situation. No history of continual obsession with body image or weight-related issues or any previous mood episode could be elicited.
She started visiting the Otorhinolaryngology department at different institutions at the age of 21 years old and after testing out all organicity (both clinical examination and barium swallow did not disclose any obstructive pathology) she was referred to the General Surgical unit.
While waiting for the surgical clinic’s appointment, the patient came to the author’s clinic for a trial of hypnotherapy intervention. On the mental status examination, the patient was alert and oriented, fixation on the disproportionate worry of being choked if she ate food. Insight was preserved i.e., she understood that her fear was unreasonable, inconsistent and mostly psychological and settled for treatment. A diagnosis of phagophobia was established.
The initial session required the taking of a full medical and social history, encompassing questions constructed to provide information about the patient’s psychological state, notably with concern to anxiety, depression from her swallowing difficulty, and of the extent of her desire towards recovery. To have a beneficial therapeutic relationship between the clinician and the patient, one should better handle the patient’s presenting complaint and take into account the perceptions and interactions of the patient and physician (Anand,2019). Consultation on the method of hypnotherapy, benefits and signed consent was taken.
During the first session, hypnosis was induced with passive, nonauthoritarian techniques (Hartland, 1971), eye fixation and progressive muscular relaxation. Suggestions aimed to achieve general relaxation, using Hartland’s ego-strengthening protocol (Hartland, 1971) tailored to suit the patient’s needs: which included, suggestions of psychological and physical well-being, feeling calm, lessening of tension, increased confidence, ability to cope with problems resourcefully and without excessive anxiety, and better sleep pattern. Care was taken not to use suggestions that can trigger undesirable experiences, thus preventing the patient from going into a relaxed state (Anand,2018).
Once the patient appeared more relaxed and in a hypnotic state of mind, underlying emotional issues were examined and dealt with. At this stage, we managed to establish, the onset of the phobia, (she was 21 years old). She managed to identify her emotional being depressed at learning her mother had advanced liver carcinoma. She has not completely accepted her mother’s fate, back then. At that age, she simply accepted that news and kept busy taking care of her mother.
On the second session, after inducing patient into hypnosis as in the first visit, patient’s feed-back of any improvement while the patient was in hypnosis elicited. Following this, the author used a cognitive behavioural strategy which involved un-coupling the anxiety response from the feared situation (for this patient it was her fear of swallowing solid food)
The focus for this patient was to identify irrational thinking patterns (her fear of choking as she swallows food), and guide her to hold on to fresh, more adaptive behaviours and thinking processes when it comes to swallowing. Under hypnosis, the patient was encouraged to visualise taking in food in a more mindful manner, chewing the meal and gradually visualising the swallowing track being in a more relaxed state(oesophagus). Visualising the muscles in the oral cavity and oesophagus being relaxed as the food passes by at ease.
CBH for this subject involved 3 approaches, Cognitive Restructuring, Systematic Exposure, and Mindfulness Training.
1. Cognitive Restructuring: this patient had catastrophic thoughts in relation to their phagophobia. This patient underestimated her capacity to cope with fear during mealtime. Cognitive restructuring thought her to establish counter-productive thought systems, and change them with more rational expectations, which result in reduced anxiety and avoidance. For illustration, counterproductive thought in her was avoiding eating with friends, as her fear of swallowing and not being able to eat food would make her friends find her company uncomfortable. Replacing with a more effective thought was, aiding her to visualise, she was in the company of her friends eating, in a small amount and not paying attention to her swallowing effort. To use the friend’s conversations as the centre of her awareness as she eats.
2. Systematic Exposure: Exposure is by supporting the patient to work out regular contact with eating solid food, and frequently exposing herself to the feared stimulus (swallowing food) until it elicits little or no apprehension. This acts by adopting a graded manner, in which the slightest anxiety-provoking stimulus is the starting point (small quantities/fragments of solid food). Once the initial stimulus was grasped, she was exposed to a stimulus that was marginally more provoking. Throughout this process she was encouraged to drink a small amount of water, to ease her swallowing effort.
3. Mindfulness Practise: Mindfulness is a practice of drawing the patient’s awareness to the present. This patient was often so hooked up by her worries about what she anticipated. She had difficulty in recognising that, when she experiences the feared scenario, it actually presents no threat. By making her mindful of her eating routine and thinking about the relaxation of her oesophagus, she was able to realise the commencement of the anxiety. Instead of allowing herself to be absorbed into the experience of that anxiety, the patient was encouraged to be more mindful of her enjoyment in eating and feeling relieved.
The subsequent third and fourth visit was a repetition of the first and second visit. A total of 4 visits in the period of one month is needed for this patient to have the phagophobia resolved. It has been 6 months since the last session, and the patient has been well, with no phagophobia symptoms. She is still under the author’s follow-ups via phone calls and has been well so far.
Phagophobia and swallowing phobia are other frequently used synonyms of choking phobia (McNally RJ, 1994). Prior to designating a patient psychogenic origin of the dysphagia, physicians need to rule out organic dysphagia. It has been proposed that Phagophobia occurs commonly secondary to a conditioning experience of being choked by food during a profound emotional struggle.
In this case, swallowing food became conditioned with the fear of being choked after learning her mother developed liver carcinoma. This contributed to a restraint of food, panic attacks and weight loss in this patient. Panic attacks in this case served as a fear conditioning factor and maintained the vicious cycle of anxiety leading to avoidance.
Existing literature (Baijens LW, 2013) indicates that phagophobia has been most frequently seen in females but in a very wide range of age groups (i.e.as low as 5 years to as high as 78 years). Comorbidity with other psychiatric disorders like social anxiety, panic disorder, personality disorders, depression etc. has been reported (McNally RJ, 1994). Currently, no controlled trials or protocols are available for the treatment of choking phobia. Existing case studies illustrate a range of treatment approaches varying from hypnotherapy (Reid DB,,2016) Eye Movement Desensitization and Reprocessing (EMDR) ( de Jongh A , 1998) and cognitive behaviour therapy (Baijens LW, 2013). Treatment protocol consisting of psycho-education, cognitive restructuring, aversion /distraction and in-vivo exposure resulted in the remission of symptoms in patients with choking phobia (Baijens LW, 2013). The treatment approach, in this case, was comprehensive (i.e., psycho-education, cognitive rechallenging and in-vivo exposure during CBH) which contributed to complete and sustained remission.
The index case highlights that clinicians should be aware of this disorder along with the fact that psychogenic dysphagia needs to be evaluated in detail. Patients with established pseudo-dysphagia with phagophobia can be considered for Cognitive Behavioural Hypnotherapy. Hypnosis is an effective technique of therapy, being practical in reducing anxiety and strengthening the patient’s confidence. It contributes to a lowered use of pharmacological agents, is not time-consuming if the patient is taught self-hypnosis, and is not troublesome to apply. For all these reasons it should be more generally utilised as an option in managing the psychogenic origin of dysphagia (pseudo-dysphagia)
The patient signed an informed consent form and agreed to the publication of this case report.
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Dr. Anand Chandrasegaran
Consultant Anaesthesiologist & Critical Care Medicine
MBBS (UM) M.MED Anesthesia (UM)
Hypnotherapy Pain Specialist, PDCH, MBSCH ( fellow BSCH)