K is a 51 year-old woman who presented for treatment on the recommendation of her primary care physician (PCP) because of a profound fear of swallowing. A swallow test was unremarkable and pointed to psychogenesis as the primary cause.
Upon psychological evaluation the patient revealed two compounding events which had caused considerable problems with eating for 40 years. The first incident occurred at age 11 when K was eating by herself and choked to the degree that she briefly thought she was going to expire.
From that date to the second precipitant, K experienced eating-related anxiety at each meal as manifested by extreme care chewing and swallowing food. Her precautions, while effective in one sense, resulted in her not being able to enjoy mealtimes.
The second precipitant was her contracting Guillain-Barre Syndrome (GBS) several years ago. GBS is a terrifying autoimmune reaction in which she lost motor and sensory control of her body. Paralysis and loss of sensation begins at the feet and steadily works its way up the body to a devastating effect both physically and psychologically.
In K’s case, the prospect of the progression of illness reaching her throat and choking her to death was overwhelming. Fortunately, the progression reversed itself at chest level and after several months of physical therapy the patient made an impressive recovery and was able to resume a normal life – with one exception.
K’s swallow phobia intensified dramatically. Eating and drinking became a chore. She was forced to hold and liquefy every small bite of food she ate while taking frequent brief breaths of air and small sips of water. Needless to say, this proved to be embarrassing for her especially when eating in public, which she avoided as much as possible.
Until her PCP noticed her odd ritual and inquired about it, K never had professional intervention even in the hospital and rehab facility she was in for months. Her M.D. referred K to me after which I implemented the following treatment regimen.
To reduce K’s anxiety about her preoccupation with choking, I recommended scheduled Buspar, a non-addictive anxiolytic, which in her case was very effective. Once her defenses were sufficiently suppressed, we started a course of brief cognitive behavioral therapy (CBT) designed to instill a sense of control over her phobia.
This was accomplished by first re-exposing K to the traumatic experiences that precipitated her chronic fears. The details of each precipitant were only reviewed once but it was sufficient to initially desensitize her to reminders of her traumas. (Such events can be revisited if necessary.)
The second phase of brief (four to six sessions) psychotherapy was to generate positive associations of eating to the aversive stimuli that repeatedly occurred with any food, drink or mealtime reference. Gradually, the negative associations were reconditioned and converted to a more positive emotional response. As a result, for the first time in years the patient began enjoying the simple pleasure of eating.
K’s progress does not mean that she is not frequently reminded of her trauma, so she still takes some care in how she eats and drinks. For example, occasionally she still takes small portions and eats and drinks relatively slowly so as not to overwhelm herself. Overall she has increasingly enjoyed eating to the degree that she frequently catches herself not thinking of her trauma throughout the entire meal.
To ensure future stability and prevent a relapse of symptoms, CBT was used to inoculate the patient against the future prospect of her choking or being around someone else who is. In these scenarios K feels that she can now pre-empt panic by reminding herself that in fact she can control this most basic act and thereby restore a quality of life lost to her for many years.
Norman M. Shulman, Ed.D., is a psychologist with a private practice in Lubbock, Texas. His email address is: firstname.lastname@example.org.