Cognitive-behavioral treatment of choking phobia: 3 case studies

Origins and outlook of interoceptive exposure

BACKGROUND AND OBJECTIVES

Interoceptive exposure (IE) is a behavioral intervention that reduces anxiety sensitivity and distress associated with somatic sensations. In this discussion, we describe the history, current applications and additional clinical potential of IE.

METHOD

We review the origins of IE and its historical application to panic disorder, as well as the accumulating evidence for transdiagnostic application to other disorders including post-traumatic stress disorder, social anxiety disorder, specific phobias and physical disorders. Then, we discuss ways in which IE could contribute to the treatment of additional disorders.

RESULTS

IE is well-established in the treatment of panic disorder and increasingly used to target anxiety-provoking physical sensations in other disorders. Research and clinical evidence suggests that anxiety sensitivity is present across a range of disorders, and may actually be one variation on a broader phenomenon of interoceptive sensitivity, or anxiety focused on physical sensations that have been conditioned to unpleasant emotional states. Moreover, somatic symptoms are central to the experience of most emotions and may contribute to avoidant coping, a maintenance factor for disorders of emotion. IE has potential as a transdiagnostic intervention targeting interoceptive sensitivity in disorders such as depression and eating disorders. Nevertheless, IE is underutilized by clinicians in practice. Recent research in inhibitory learning and extinction suggests strategies for maximizing the effectiveness of IE.

LIMITATIONS

This review is not exhaustive in nature, and systematic research on transdiagnostic applications of IE remains scarce.

CONCLUSIONS

IE is a potentially powerful yet understudied transdiagnostic intervention.

A Case Study of Hypnosis for Phagophobia: It's No Choking Matter

In this case study the author reviews the benefits of hypnosis for a 13-year-old female suffering from a specific phobia involving a fear of choking and generalized fear of swallowing that resulted in an episode of Restrictive Food Intake Disorder with associated significant weight loss. At the time of the initial consultation, three weeks after her choking episode, the patient weighed 93 pounds. Standing at 5'2", her Body Mass Index (BMI) was 17 (15th percentile) indicative of healthy weight for a child her age and height. She continued to lose weight over the course of 2 months and at her worst weighed 85 pounds (BMI = 15.5, 3rd percentile, classified as underweight). Prior to the incident, she weighed 105 pounds with a BMI of 19.2 (46th percentile). Treatment initially consisted of 12 hypnosis sessions (over a 5-month period), conducted on a weekly and eventually biweekly basis. A scheduled one-month follow-up visit was conducted following the 12th session, at which time the patient was consuming solid foods without fear of choking. Her BMI at that time was 18.7 (39th percentile). Two months after terminating treatment, the patient experienced a mild relapse triggered by conflicts with some female peers. After four additional hypnosis sessions, the patient's symptoms again remitted. During her last session we shared a pizza, providing clear and convincing evidence that she had overcome her fear of swallowing. She retained therapeutic benefits for at least 3 years following treatment.

Phagophobia: a case report

Background

Phagophobia is a rare disorder and the literature is sparse. There is no specific treatment described for this life threatening condition.

Case presentation

The patient is a 25-year-old Sri Lankan female with recurrent difficulty in swallowing. Following her initial episode which lasted one year, she presented to us with inability to swallow for one week. She was dependent on liquids and semisolids. The medical team confidently excluded an organic cause. She had difficulty swallowing solids with behaviours like swallowing with the aid of water and swallowing small boluses. She had difficulty eating in front of a crowd as well. She was preoccupied with misconceptions related to food and gastrointestinal disorders like gastritis. The symptom was soon becoming a maladaptive coping mechanism as it occurred when she was under stress and had difficulty solving a problem. The patient was managed with graded exposure and cognitive techniques.

Conclusion

The possibility of a psychological cause for dysphagia should be borne in mind although the occurrence is rare. Although no definitive treatment methods for phagophobia are described, cognitive behavioural techniques can successfully be used in the treatment.

A case of choking phobia: towards a conceptual approach

Choking phobia, also known as phagophobia or swallowing phobia is an uncommon clinical entity that has been underappreciated and is included in the new DSM-5 and upcoming ICD-11 diagnostic category of avoidant/restrictive food intake disorder. Phenomenologically distinct from other eating disorders, it is characterized by the phobic stimulus of swallowing that results in the avoidance of food or drinks, and ultimately to low weight, social withdrawal, anxiety and depression states. Its prevalence and long-term course on the general population still needs to be determined, probably reflecting years of indefiniteness regarding its nosology and by the absence of a clear set of diagnostic criteria. We present a clinical case of choking phobia in a 32-year-old male patient after an episode of choke when eating chicken. An early diagnosis and distinction from other eating disorders is important for proper treatment and fundamental for prognosis. We also make a thorough revision on literature in clinical features, differential diagnosis and treatment approaches, suggesting a conceptual approach for choking phobia as a clinical spectrum settled by different degrees of phobic subtypes, which may depend on a varied number of clinical variables.

Collaborative Treatment of Choking Phobia in an Older Adult

This article describes the case of a 69-year-old man with a long history of swallowing difficulties and a past diagnosis of obsessive-compulsive disorder. He was seen for treatment by a speech-language pathologist and a clinical psychologist. Prior to treatment, he ate only one type of sweet dessert and some pureed foods, at restricted times of the day, and without others present. Treatment focused on increasing variety in his diet, increasing bolus size, reducing ritualistic and safety behaviors, and eating in social situations. Treatment methods included surface electromyographic biofeedback and systematic desensitization. After 19 months of treatment (49 sessions), the patient was able to eat a variety of soft/ground foods. He gained weight and was able to eat in social situations. At post-treatment, 8-month and 48-month follow-up, he reported being satisfied with his progress and did not wish to pursue further goals involving eating solid foods or increasing bolus size of liquids.

Diagnosis and treatment of phagophobia: a review

This narrative review summarizes published studies on diagnostic examinations and therapeutic interventions for phagophobia. The electronic databases Embase, PubMed, PsycINFO(®), and The Cochrane Library were used. The literature search was limited to publications in the English, German, French, Spanish, or Dutch language. The original articles are summarized in the present narrative review. The body of literature on phagophobia and swallowing fear remains very limited; only 12 studies were found. The present narrative review discovered heterogeneity in the definitions of phagophobia or similar syndromes. A systematic review, including a qualitative analysis, was planned but not carried out as studies were not of sufficient quality to warrant doing so. All the studies had severe methodological shortcomings. In general, the conclusions could not be compared across the studies because of the different study designs, small populations, different ways of evaluating and treating phagophobia, and complex combinations of treatments. A general conclusion is provided.

Phagophobia: Behavioral Treatment of a Complex Case Involving Fear of Fear

Phagophobia is the avoidance of swallowing foods, liquids, or pills, usually based on a fear of choking. Since the first reported case study in behavior therapy, cases reported in the cognitive-behavioral literature reveal that ostensibly different approaches have yielded similarly positive outcomes. A limited number of fundamental behavioral mechanisms appear to underlie the various manifestations of swallowing phobias. These may account for effectiveness of different cognitive-behavioral treatment protocols. This article describes a new case of phagophobia in an adult male client, revealing some of the variables that need to be considered in assessment and treatment. As the case described contained elements of body dysmorphic disorder, fear of choking, social anxiety, and fear of fear, it demonstrates subtleties of treatment design and the importance of adhering to sound behavioral principles and the value of a sophisticated functional analysis.

Behavioral treatment of choking phobia in an adolescent: an experimental analysis

A multiple baseline approach across foods was used to evaluate an exposure-based treatment for choking phobia in a 13-year-old girl. Following 14 sessions, the patient demonstrated substantially reduced self-reported, observer-rated, and parent-reported anxiety, increased eating rate and bite size, and increased variety of food intake. Clinical diagnoses present at pretreatment were not present at posttreatment at a clinical level. These gains were maintained at a 9-month follow-up assessment.