What is Phagophobia?

Phagophobia is a type of specific phobia characterised by an extreme and overwhelming fear of swallowing. It is a relatively rare phobia with low diagnostic rates, but it can be a debilitating condition that can have a significant impact on your health, your day-to-day life and your overall well-being.

Today, we are going to look at phagophobia in more detail, including the common causes, triggers, symptoms and treatments. 

What is Phagophobia?

Phagophobia is an extreme, irrational, overwhelming and persistent fear of swallowing. It is a relatively rare type of phobia. This phobia is characterised by an intense and irrational fear of swallowing, which can include a fear of eating, drinking, swallowing your own saliva and taking oral medication. Someone with phagophobia will experience intense feelings of fear, anxiety or panic when swallowing or at the thought of swallowing. They may also experience anticipatory anxiety in the lead-up to swallowing, for example in the run-up to mealtimes. 

Phagophobia is a type of specific phobia, meaning it is a lasting, overwhelming and unreasonable fear of a specific object, situation, activity or person; in this case, an overwhelming fear of swallowing. You may experience negative thoughts, feelings and behaviours surrounding swallowing. These negative thoughts and feelings can significantly impact your day-to-day life and your mental and emotional health and well-being.

Phagophobia goes beyond typical aversions that people may have to certain foods or drinks. This phobia can have serious implications on your ability to eat a regular and balanced diet. It can lead to avoidance behaviours in relation to food and drink, restricted food and drink intake and can have serious health consequences. Without treatment, someone with phagophobia is at risk of dehydration, malnutrition and serious weight loss. 

Phagophobia is often confused with pseudo-dysphagia, which is a fear of choking. Although someone with phagophobia may also fear that swallowing could result in choking, this may not be the primary basis of their fear and, for some people with phagophobia, there is no fear of choking. For example, their phobia may centre around a dislike of the sensation of swallowing or a fear of what they are putting in their bodies. 

It is possible to have issues surrounding swallowing that are not related to phagophobia. It is also normal for someone to experience a reluctance to swallow a certain food or drink or have temporary issues surrounding swallowing following a specific event, such as a throat infection. To be diagnosed with phagophobia, your fear of swallowing could be characterised by:

• Experiencing stress and anxiety at the thought of swallowing.
• Restricting your food and drink intake and refusing to take oral medication.
• Avoiding situations where you may have to swallow, such as avoiding going out to eat.
• Engaging in unusual behaviours surrounding swallowing, such as grinding up your medication or only eating soft foods.
• Feelings of intense fear, panic or anxiety that are difficult to manage.
• Fear or anxiety that is out of proportion to the true risk.
• 
  A fear of swallowing that has lasted for at least six months.
• Engaging in avoidance behaviours to prevent the need to swallow or to reduce the intensity of swallowing (such as only eating soup).
• A fear of swallowing that interferes with your day-to-day life, overall well-being or sense of safety.
• Experiencing anticipatory anxiety or worry when thinking about swallowing.

A fear of swallowing can be so intense and overwhelming that someone with this fear may avoid any place or situation that they relate to swallowing. For example, they may refuse to attend social events involving eating or drinking, they may avoid going outside when it is hot so they don’t have to drink extra water, and they may avoid going to the dentist in case they need to swallow anything. Although you may implement avoidance behaviours to help you avoid your triggers and prevent feelings of anxiety, this can actually have a paradoxical effect. Avoidance behaviours can result in more severe fear and anxiety and more severe physical, psychological and behavioural symptoms if you are faced with your triggers in the future. 

If you have phagophobia, you may be aware that your fear of swallowing is irrational, and that swallowing doesn’t actually pose a threat to you. However, you may be unable to control your fear and anxiety and manage or prevent any physical, psychological or behavioural responses to your triggers.

Phagophobia can be connected to or occur in conjunction with other phobias, including:

• Pseudodysphagia: A fear of choking.
• Cibophobia: A fear of food.
• Aquaphobia: A fear of water, including drinking water.
• Algophobia: A fear of pain.
• Obesophobia: An extreme fear of gaining weight or getting fat.

Phagophobia can also be related to other health conditions, including:

• Food aversion: Where particular food textures, flavours or smells cause feelings of nausea or vomiting.
• Dysphagia: Difficulties or pain when swallowing, usually as a symptom of a disease.
• Odynophagia: Pain (usually an ache, burning sensation or a stabbing pain) in the mouth or throat when swallowing.
• Eating disorders: Including anorexia and bulimia.

How Common is Phagophobia?

Phobias are often a significantly underdiagnosed medical condition. In particular, phagophobia is much less well-known and less frequently diagnosed than other more common phobias. 

There are many reasons why phagophobia may be underdiagnosed, including:

• It may be misdiagnosed as another health condition or phobia, such as food aversion. This is particularly likely in children and young people.
• Many people with a fear of swallowing have never heard of phagophobia so may not realise they are experiencing a diagnosable medical condition.
• Many people are unaware that there are effective treatment options available for phobias so may never seek a diagnosis or medical intervention.
• People with phobias often implement avoidance behaviours that reduce or remove their contact with their triggers, which makes their phobia more manageable.
• Adults with phagophobia may be embarrassed by their fear and may not want to tell their GP or other people about the way they are feeling.

Phagophobia can occur in people of all ages but is most frequently diagnosed in children and adolescents. 

Who is at Risk of Phagophobia?

Although anyone can develop phagophobia, certain risk factors can make it more likely that you will develop phagophobia, for example:

• Previously having a traumatic, negative, scary or painful experience involving swallowing.
• Previously having a traumatic experience involving eating.
• Having an anxiety disorder or another mental health condition.
• Hearing or witnessing a traumatic or scary experience involving swallowing, for example witnessing someone choking.
• Being exposed to a fear of swallowing at a young age.
• Having a close family member, for example a parent or sibling, with phagophobia.
• Having a close family member, for example a parent or sibling, with another phobia.
• Being a naturally more anxious or nervous person.
• Experiencing a significant life stressor, having higher than usual stress levels or being in a heightened mental state (particularly if you are exposed to a fear of swallowing or have a negative experience involving swallowing during this time).
• Having a substance use disorder, such as an addiction to drugs or alcohol.

How to Deal with Phagophobia

As well as official treatment options, there are also effective coping and calming strategies that can be combined with lifestyle changes to help you manage your phobia, alleviate your symptoms and reduce the impact your fear of swallowing has on your life.

Some of these strategies are most effective when you implement them long term, meaning you engage in them regularly on a long-term basis, for example daily or weekly. They can help to reduce the frequency and severity of your symptoms over time and enable you to be in triggering situations in the future without experiencing negative thoughts and feelings.

Short-term strategies are designed to be implemented when you are faced with your triggers, when you begin to experience symptoms or in the lead-up to a triggering situation. They are effective in minimising or preventing your phobia symptoms and preventing a triggering situation from worsening and your negative thoughts and feelings from taking over.

Some strategies you can implement to help you deal with your phobia of swallowing include:

Learn to understand and accept your phobia

Acknowledging your fear of swallowing is the first step in overcoming your phobia. This acknowledgement and acceptance allows you to confront your phobia and explore your underlying feelings, behaviours and any damaging beliefs and thought patterns that might be contributing to your fear. Understanding and accepting your fear allows you to change your thoughts and behaviours when faced with your triggers. This acceptance also allows a better understanding of any thoughts and beliefs surrounding swallowing, which can reduce the severity of your phobia. 

Set achievable goals 

Creating a list of short-term and long-term goals can help you to stay motivated and hold yourself accountable. Your goals could include new foods you want to try, going to a coffee shop with a friend or drinking your target amount of water each day. Goals give you a long-term vision, such as no longer being fearful of swallowing, and short-term motivation. Setting goals can also help you to change problematic behaviours and encourage new positive behaviours. It can also keep you motivated to overcome your phobia. 

Visualise yourself overcoming your fear 

Visualisation strategies can be extremely effective in helping you to overcome your phobia in the long term and reduce any fear or anxiety you usually feel in the moment. Visualisation involves visualising yourself in triggering situations and successfully confronting and overcoming your fear. For example, you could visualise yourself eating dinner in a restaurant with your friends without feeling any anxiety. Visualisation gives you something to aim for and can reassure your brain that there is no danger. It can also help to reshape your thoughts and beliefs regarding swallowing so that you are less likely to experience an automatic fear response in the future. 

Challenge negative thoughts and feelings 

If you have a phobia of swallowing, you may find yourself dreading triggering situations, thinking about swallowing negatively or obsessively planning how to avoid your triggers. You may also begin to imagine the worst-case scenario and all the bad things that could happen, for example that your medication will get stuck in your throat, and you won’t be able to breathe. Instead of allowing any negative thoughts to take over, try to disrupt your thoughts to prevent your fear from escalating. Remind yourself that your fears are not accurate and you are not in any danger. In triggering situations, remind yourself that your thoughts and feelings will soon pass, and your fear is disproportionate to the risks.

Create a fear ladder 

A fear ladder can help you to analyse and understand your fear of swallowing and can also help you to identify which of your triggers creates more severe fear, anxiety and panic than others. When creating your fear ladder, your triggers will be organised from least severe to most severe. Because phobias are highly individualised, everyone’s fear ladder is different. Although your fear ladder may look different, an example is shown below:

• 1 = Eating chewy or crunchy foods, such as steak or an apple.
• 2 = Swallowing tablets.
• 3 = Eating or drinking when you have a cold or sore throat.
• 4 = Eating or drinking in front of other people.
• 5 = Swallowing a thick drink, such as a milkshake.
• 6 = Eating sticky food, such as marshmallows.

Once you have created your fear ladder, you can then confront your fears one at a time, starting at the bottom of the ladder (the trigger that results in the least phobic response). This can help you to build up your tolerance of your triggers gradually and reduce your fear of swallowing long term.

Tell your support network about your phobia 

Some people attempt to hide their phobia, experiencing embarrassment at the prospect of others discovering their fear. However, keeping your phobia hidden can have adverse effects. Opening up about your phobia to those close to you, including family, friends and trusted colleagues, can be beneficial. Other people understanding your fear and being aware of situations that may be difficult for you enables them to be more considerate of the triggers of your phobia, for example not eating in front of you, and allows them to offer support.

Attend a support group 

Attending a support group with other people who have had similar experiences to you can be extremely beneficial. You could attend an in-person or online support group with other people with phobias. A support group can help to validate your thoughts and feelings and allow you to receive advice, reassurance and empathy from other people who understand your experience.

Implement distraction techniques 

If you are in a triggering situation or need to eat, drink or swallow medication, implementing distraction techniques can help to reduce your physical and psychological responses to your triggers. Distraction techniques could include listening to music, engaging in conversation, reading, playing a game or watching a video. Focusing on something external, such as counting the number of objects in a room or the number of passing cars, can also help to keep you calm.

Practise deep breathing 

Deep breathing can be an effective short-term relaxation technique and can help you manage the symptoms of your phobia. Systematic deep breathing sends a signal to your brain to relax, which can reduce your feelings of anxiety. Regular deep breathing exercises can be effective in lowering stress levels, alleviating bodily tension, and gradually reducing your overall anxiety. Practise deep breathing for at least 10 minutes or until symptoms subside. Integrating deep breathing exercises into your daily routine can also be beneficial. 

Practise mindfulness 

Mindfulness teaches you how to accept your thoughts and feelings and can be an effective tool to help you manage the symptoms of your phobia. Mindfulness teaches you how to focus your breathing and attention, which can reduce your anxiety and the likelihood that you will experience a panic attack. Practising mindfulness on a regular basis can also reduce your overall stress and anxiety and teach you how to be more in control of the connection between your mind and body.

Practise yoga and meditation 

Yoga and meditation are popular strategies for reducing your overall stress and anxiety. They can help you enter a more relaxed state and decrease your stress levels. They can also teach you how to enter a meditative state, control your breathing and manage your body and mind’s negative reactions to your triggers. Practise yoga and meditation regularly to reduce the impact your phobia has on your day-to-day life and improve your symptoms.

Make lifestyle changes 

There are specific lifestyle factors that are associated with increased anxiety, which can in turn worsen the symptoms of your phobia. By making changes to your lifestyle, you can reduce your anxiety and the impact your phobia of swallowing has on your life. Some of the lifestyle changes you could make are:

• Implement a successful sleep routine.
• Reduce your daily stress.
• Implement an exercise routine.
• Avoid caffeine, sugar and other stimulants.
• Avoid alcohol and recreational drugs.
• Stop smoking.

What Triggers Phagophobia?

A trigger, also known as a stressor, is an object, person, place, situation or thought that triggers a negative reaction and negative thoughts and feelings, such as fear, panic, anxiety or distress. A trigger can also lead to physical, behavioural and other psychological symptoms. Your brain perceives a trigger as a threat to your physical or mental safety or well-being and will react accordingly.

The triggers of phagophobia are the things that trigger your phobia and cause you to experience adverse symptoms. Many different things can trigger your phobia. Some people have one main trigger, whereas, for other people, many things can trigger the symptoms of their phobia. Triggers can vary from person to person and in different situations. 

The types of triggers you experience can vary, depending on:

• What initially caused your phobia of swallowing to develop.
• Your specific fear in relation to swallowing.
• Your perception of the potential dangers in the specific situation.
• Your current mental health and well-being.
• The severity of your phobia.

The most common triggers of phagophobia are listed below:  

• Swallowing, including eating, drinking and taking oral medication.
• Having a cough, a cold, a sore throat or another illness that may cause your throat to hurt or swell.
• Going to a place where eating and drinking are expected, such as a restaurant or café.
• Visiting the dentist.
• Seeing someone eat crunchy or chewy foods.
• Hearing someone cough while eating or drinking.
• Visiting the doctor (in case they tell you that you need oral medication).
• Seeing other people eat or drink.
• Hearing a story about someone choking.

What are the Symptoms of Phagophobia?

The symptoms of a phobia can be: 

• Physiological – related to your body.
• Psychological – related to your mind.
• Behavioural – related to your behaviour.

Symptoms are negative changes that you experience when you are faced with a trigger. The symptoms of phagophobia can vary and often differ from person to person. The symptoms can differ in the types of symptoms you experience, the way they manifest and their severity. Symptoms are often automatic and uncontrollable. 

Some people with phagophobia only experience a few mild symptoms whereas other people experience more severe symptoms. It is also possible to experience different symptoms in different situations. Differences in the severity of symptoms, how frequently they occur, and their manifestation can occur for multiple reasons, such as the types of triggers you face, how severe your phobia is, your perception of the situation and the potential danger and your current mental health and mindset. 

The most common symptoms of phagophobia are:

Psychological symptoms: 

• An extreme reluctance or avoidance of swallowing, including food, drinks and medication.
• Experiencing anticipatory anxiety before meals.
• Intense, overwhelming, persistent, excessive and unreasonable fear, anxiety, panic or dread when faced with your triggers.
• Feelings of fear, anxiety or panic that are out of proportion to the risks.
• Intense feelings of dread or terror in relation to swallowing.
• Catastrophising the risks and potential dangers of swallowing.
• Mood swings, irritation or anger in triggering situations.
• Feeling like you are frozen or immobilised by your fear of swallowing.
• Feeling like you have a lack of mental and physical control over your body.
• Difficulties concentrating or functioning normally in triggering situations.
• Feeling like you are losing control or are not in control of the situation.
• Experiencing nightmares.
• Having a desire to run away or hide when faced with your triggers.
• Feeling like you are in danger or having a sense of impending doom.
• Feeling like you are dying or are going to die.

Physiological symptoms:

• Dizziness or light-headedness.
• Confusion or disorientation.
• Unusual or excessive sweating or clamminess.
• Uncontrollable shaking or trembling.
• Chills or hot flushes.
• Pale or flushed skin (particularly on your face or neck).
• A dry or sticky mouth.
• Chest pain or feeling a tightness in your chest.
• Having breathing difficulties, such as hyperventilating, shortness of breath or rapid breathing.
• Feeling like you cannot catch your breath.
• Experiencing heart palpitations, increased heart rate or feeling like your heart is pounding.
• Increased blood pressure (hypertension).
• A choking sensation, finding it difficult to swallow or feeling a lump in your throat.
• Headaches or other bodily pains that don’t occur at other times.
• Muscle tension or feeling like your muscles are stiff.
• Feeling pins and needles, particularly in your hands or feet.
• Nausea, vomiting, stomach discomfort or feeling like you’ve got butterflies in your stomach.
• Increased sensitivity to hot and cold temperatures (e.g. feeling like you are extremely hot even though the room temperature is normal).
• Panic attacks.

Behavioural symptoms:

• Eating very small mouthfuls or over-chewing your food to aid in swallowing.
• Refusing to eat solid food and consuming only liquids.
• Refusing to eat or drink in front of other people.
• An extreme reluctance or avoidance of swallowing, including food, drinks and medication.
• Avoiding social or professional events that involve eating or drinking.
• Refusing to think about or talk about swallowing or your particular triggers (e.g. swallowing medication).
• Refusing to watch a TV show or film featuring eating or drinking.
• Becoming socially withdrawn.

Physical consequences of your phobia:

• Malnutrition or weight loss.
• Dehydration.
• The physical consequences of not taking oral medication.

What Causes Phagophobia?

There is not one specific cause of phagophobia. Some people with this phobia can identify exactly what triggered their fear of swallowing. For other people, a combination of different factors can contribute to them developing this phobia.

Identifying and understanding the root cause of a phobia can be beneficial in helping you overcome your phobia and reduce the severity of your symptoms and the impact your fear has on your life. The causes of phagophobia can be psychological, environmental, societal or evolutionary. 

The most common causes of phagophobia are listed below:

Negative experiences surrounding swallowing

A previous negative experience involving food or swallowing can trigger phagophobia. This is one of the most common causes of phobias and is also referred to as a direct learning experience or traumatic conditioning. The negative experience may or may not have involved real danger or risk; however, as long as you experienced significant fear, distress or trauma, this can lead to you developing a phobia. A traumatic experience is more likely to cause a phobia if it occurred during childhood or during a particularly vulnerable time in your life. The experience may be direct, meaning it happened to you, or indirect, meaning you witnessed it happening to someone else. 

Examples of negative experiences that can cause phagophobia include:

• Previously choking, particularly if you thought you were going to die.
• A painful medical procedure, such as a tracheotomy.
• Traumatic experiences involving regurgitation.
• Previously experiencing bulimia.
• Having an embarrassing experience relating to swallowing, eating or drinking.
• Previously experiencing sexual or physical abuse or assault.

Hypersensitivity to pain 

People who are hypersensitive to pain may have an extreme, negative response to pain or the possibility of pain. The increased pain they feel when swallowing can result in them developing a negative association between swallowing and pain, which can then develop into a phobic response.  

Experiencing anxiety or long-term stress 

For many people, the symptoms of anxiety include tension in the throat and chest and feeling like they have a lump or blockage in their throat. This can cause further anxiety when swallowing, as it can make you feel like you are unable to swallow, or your throat is blocked, and you may choke. This can cause an aversion or fear of swallowing. Additionally, significant long-term stress can result in a disproportionate fear response or an inability to manage intense situations. This can make it more likely that you will develop a phobia. 

Fear rumination 

Fear rumination usually occurs following a negative encounter relating to swallowing. Fear rumination involves engaging in repetitive negative thought processes and persistently and repeatedly recapping traumatic, scary, negative or painful experiences. Over time, these thoughts and memories can become increasingly upsetting and intrusive and can make you remember the event as being more negative or scary than it was in reality. Fear rumination reinforces your natural fear responses, creates additional anxiety and can result in you developing phagophobia.  

A learned phobia 

Also known as an observational learning experience, a learned phobia usually means you observed a fear of swallowing or another similar fear in someone else and learnt to be scared of it yourself. You are more likely to learn a phobia if you are exposed to it during childhood or adolescence. For example, children who grow up with a close family member, such as a parent or sibling, with phagophobia, are more likely to develop the condition themselves. However, a learned phobia can also develop during adulthood.

How is Phagophobia Diagnosed?

If you are experiencing symptoms consistent with phagophobia, you should make an appointment with your GP or primary healthcare physician.

During your appointment, your GP will try to determine whether you are experiencing abnormal levels of fear and whether your symptoms are consistent with phagophobia. They may also look at your medical history, any other health conditions you have and any medications or supplements you are taking to ensure your symptoms cannot be attributed to another source. 

If your GP thinks your symptoms are consistent with phagophobia they will likely refer you to a psychologist or phobia specialist. You will be asked to provide information about:

• The types of symptoms you experience, how frequently they occur and how severe they are.
• The initial onset of your phobia, including when your symptoms first began and what initially triggered your fear of swallowing (if you know).
• Your medical history, including whether you are currently or have previously had any anxiety disorders, panic disorders, phobias or other mental health conditions.
• Whether you have a family history of phobias.
• How much your fear interferes with your day-to-day life, your well-being and your behaviour.

Because phagophobia is classified as a specific phobia, your symptoms will be compared against the diagnostic criteria for specific phobias. The diagnostic criteria are listed below.

• The fear must be persistent, excessive and unreasonable. It can occur either when the individual is swallowing or in other situations.
• Exposure to their triggers leads to an immediate anxiety response in the majority of situations.
• The fear is excessive and disproportionate to the threat, and this is recognised by the individual.
• The individual avoids places or situations where they could be exposed to their triggers. If they are exposed to their triggers, the individual will experience extreme fear, anxiety or distress.
• The anticipation of swallowing and the avoidance behaviours associated with avoiding their triggers can have a significant impact on the individual’s day-to-day life.
• The fear has lasted for a minimum of six months.
• The phobia is not associated with another disorder or mental health condition.

If your symptoms correspond with these key criteria, you will receive a diagnosis of a specific phobia (phagophobia). Depending on the severity of your symptoms, you may then be offered treatment.

How is Phagophobia Treated?

Once you have received a diagnosis of phagophobia, you may be offered treatment. There are multiple effective treatment options for phobias, including phagophobia. 

You should seek treatment for phagophobia if:

• Your fear is triggered frequently.
• You change your behaviour to avoid your triggers.
• Your symptoms are severe.
• Your phobia negatively impacts your life in any way.
• You have experienced a fear of swallowing for an extended period of time.

As there are multiple effective treatment options available, your doctor will create a personalised treatment plan that is designed to treat your phobia. Your treatment plan will be based on several factors, such as:

• The severity of your symptoms.
• The frequency of your symptoms.
• The root cause of your phobia.
• How significantly your phobia impacts your life.

The most common treatment options for phagophobia are:

Cognitive Behavioural Therapy (CBT):

Cognitive behavioural therapy (CBT), often referred to as talk therapy, is a form of psychotherapy designed to support you in understanding and managing your negative thoughts and emotions. For people with phagophobia, thinking about swallowing in a negative light and associating it with danger or fear, can give rise to automatic negative thoughts, feelings and behaviours. CBT includes the process of recognising and reshaping your fear of swallowing, along with any associated negative beliefs, thought patterns, emotions and behaviours.

The primary objective of CBT is to help you unlearn harmful thought processes and behaviours and replace them with more positive ones. Throughout the CBT sessions, you will look at the cause of your fear of swallowing and any harmful beliefs, thoughts and emotions linked to the initial development of your phobia.

During your CBT sessions, you will likely work on:

• Understanding your triggers and what initially caused your fear of swallowing.
• Recognising distorted patterns of thinking.
• Changing any unhealthy beliefs surrounding swallowing.
• Coping strategies and calming strategies, such as deep breathing exercises, distraction techniques and coping statements.

Clinical Hypnotherapy:

Clinical hypnotherapy can be an effective treatment for phobias. During the hypnotherapy sessions, you will enter a deeply relaxed yet focused state. Whilst you are in this state, the focus is on recognising and addressing any negative thought patterns, beliefs, memories, feelings or behaviours contributing to your phobia. The hypnotherapist’s role is to guide you in understanding your fear of swallowing and reshaping your negative thought processes.

The process of hypnotherapy involves a combination of directed relaxation techniques and concentrated attention to assist you in overcoming negative thoughts and emotions related to swallowing. Throughout the sessions, you will also learn techniques for relaxation.

Medication:

Medication will likely not be prescribed as a sole treatment option for phagophobia. However, medication may be prescribed if you also experience another mental health condition, such as anxiety or depression, alongside your phobia. Medication can also be helpful as a short-term solution to help you manage your symptoms.

Some types of medication that may be prescribed for treating phobias or anxiety are:

• Anti-depressants.
• Beta-blockers.
• Sedatives.

Medication will usually only be prescribed alongside another type of treatment, such as CBT.