Phagophobia

Phagophobia (from Greek phagein, "to eat", and phobos, "fear") is a psychogenic dysphagia, defined as a fear of the act of swallowing.^[1] It is a relatively rare specific phobia that presents as various swallowing complaints without any apparent physical reason detectable by physical inspection and laboratory analyses.

Phagophobia
Other names	Psychogenic dysphagia
Specialty	Psychiatry, Psychology, Otolaryngology
Symptoms	Anxiety while eating, avoidance of solid foods, excessive chewing, weight loss
Complications	Malnutrition, dehydration, social isolation
Usual onset	Variable (often after a triggering event)
Duration	Chronic if untreated
Causes	Traumatic event (choking), anxiety disorders
Diagnostic method	Clinical interview, exclusion of organic causes (e.g. barium swallow)
Differential diagnosis	Anorexia nervosa, Globus pharyngis, Esophageal dysphagia

Phagophobia is classified as a specific phobia and, according to the DSM-5 classification, usually falls under the category of "Specific Phobia: Other" or "Choking Phobia".^[2] It is distinct from physical dysphagia, where a mechanical or neurological problem impedes swallowing. While formerly referred to interchangeably as choking phobia,^[3] researchers have suggested distinguishing phagophobia (fear of the mechanics of swallowing/propulsion of the bolus) from pseudodysphagia (the fear of choking), though the two conditions often overlap clinically.^[1]

The condition can lead to significant health consequences, including weight loss and malnutrition, and is often confused with eating disorders such as anorexia nervosa, despite having a fundamentally different psychological motivation.

Signs and symptoms

The primary symptom of phagophobia is an intense, irrational fear of swallowing. This fear often triggers a physiological anxiety response (panic) when the sufferer attempts to eat or drink. Individuals with phagophobia may exhibit the following behaviors and symptoms:

• **Dietary restriction:** Avoiding solid foods in favor of a liquid or soft diet (e.g., smoothies, nutritional shakes, baby food).^[4]
• **Texture avoidance:** Refusal to eat foods with mixed textures or foods perceived as "difficult" to swallow (e.g., meat, dry bread).
• **Compensatory rituals:** Excessive chewing, sipping large amounts of liquid with every bite to "wash down" food, or taking extremely small bites.
• **Physical symptoms:** Tachycardia, sweating, sensation of a lump in the throat (globus pharyngis), and muscle tension in the neck and throat during meals.
• **Psychological impact:** Anticipatory anxiety before mealtimes, avoidance of eating in public or social situations, and frustration regarding the inability to eat normally.

In severe cases, the avoidance behavior can result in significant weight loss, dehydration, and nutritional deficiencies.

Causes

Phagophobia is often precipitated by a traumatic event, though it can also develop without a clear trigger. Common etiologies include:

• **Direct conditioning:** A personal experience with choking, gagging, or difficult swallowing (e.g., a pill getting stuck).
• **Vicarious learning:** Witnessing another person choke or struggle to swallow.
• **Informational transmission:** Hearing frightening stories about choking or medical procedures involving the throat.
• **Generalized anxiety:** Individuals with high baseline anxiety or panic disorders may manifest their symptoms somatically in the throat area.

Diagnosis

Diagnosis of phagophobia is a process of exclusion. Because the symptoms mimic physiological disorders, medical professionals must first rule out organic causes of dysphagia. This typically involves a multidisciplinary approach:

1. **Medical Evaluation:** Examinations by an otolaryngologist (ENT) or gastroenterologist are conducted. Tests may include a barium swallow, endoscopy, or esophageal manometry to ensure the anatomy and motility of the esophagus are normal.
2. **Psychological Evaluation:** Once physical causes are ruled out, a mental health professional assesses the patient for specific phobia.

Differential diagnosis

It is crucial to distinguish phagophobia from other conditions:

• **Anorexia nervosa:** Unlike patients with anorexia, individuals with phagophobia usually desire to eat and do not have a distorted body image or a fear of gaining weight. They lose weight as a consequence of the phobia, not as a goal.
• **Globus pharyngis:** A persistent sensation of a lump in the throat. While often psychogenic, globus does not necessarily involve a phobia of the act of swallowing itself.
• **Avoidant/restrictive food intake disorder (ARFID):** While phagophobia can be a driver of ARFID, ARFID is a broader category that includes sensory aversion (taste/smell) or lack of interest in food, not just the fear of the swallowing mechanism.

Treatment

Phagophobia is generally treatable with psychological interventions. The prognosis is often good, especially with early intervention.

• **Cognitive behavioral therapy (CBT):** The most common treatment, involving the identification and restructuring of negative thoughts regarding swallowing.
• **Exposure therapy:** A gradual desensitization process. Patients may start by swallowing saliva, then progress to liquids, soft foods, and eventually solids. This is often done in a "hierarchy of fears" approach.
• **Psychoeducation:** Explaining the mechanics of swallowing to reassure the patient that the body protects the airway automatically.
• **Pharmacotherapy:** In some cases, anti-anxiety medications (such as SSRIs) may be prescribed to lower general anxiety levels, facilitating therapy.
• **Swallowing therapy:** Speech-language pathologists may work with patients to relearn normal swallowing patterns and reduce muscle tension.

See also

• Odynophagia (Painful swallowing)
• Pseudodysphagia (Fear of choking)
• Dysphagia (Difficulty swallowing)
• Sitophobia (Fear of food)
• List of phobias