From Fear to Recovery - Psychogenic Dysphagia and Eating Phobia: A Case Report 

From Fear to Recovery - Psychogenic Dysphagia and Eating Phobia: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report From Fear to Recovery - Psychogenic Dysphagia and Eating Phobia: A Case Report Muhammad Suliman Sunkrot, Dr. Iyad Fahmi Al-Azzeh, Saja Zaki Junaidi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6100168/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Introduction: Psychogenic dysphagia is a rare swallowing disorder with psychological origins, classified under Avoidant/Restrictive Food Intake Disorder (ARFID) in the DSM-5. It often leads to significant social withdrawal, malnutrition, and weight loss, and is commonly associated with anxiety, depression, and PTSD. Case Presentation: This case involves a 21-year-old Palestinian female who developed phagophobia after a choking incident at age 11. Over time, her fear of choking led to the avoidance of solid foods and a shift to a liquid diet. Her condition worsened, resulting in significant weight loss (55 kg to 46 kg) and severe malnutrition. She also experienced daily panic attacks and had a history of generalized anxiety disorder and other phobias. Investigation and Diagnosis: Comprehensive medical investigations, including neck ultrasound, blood tests, upper endoscopy, and flexible endoscopic evaluation of swallowing (FEES), revealed no structural abnormalities, rolling out organic causes. Psychiatric assessment confirmed a diagnosis of eating phobia. Management and Outcome: Treatment included pharmacotherapy (SSRIs, antipsychotics, anxiolytics) and Cognitive Behavioral Therapy (CBT). After three months, the patient reported a 30% improvement in symptoms and dietary intake. Long-term follow-up was recommended. Conclusion: This case highlights the importance of recognizing psychogenic dysphagia as a psychological disorder with physical manifestations. Early intervention with pharmacotherapy and Cognitive Behavioral Therapy can significantly improve symptoms and dietary intake, emphasizing the need for a multidisciplinary approach in managing such complex cases. Case report Psychogenic Dysphagia Eating Phobia Avoidant/Restrictive Food Intake Disorder (ARFID) Phagophobia Anxiety Disorders Generalized Anxiety Disorders Swallowing Disorders Figures Figure 1 Figure 2 Introduction Psychogenic dysphagia is a rare swallowing disorder caused by psychological rather than anatomical or organic factors [ 1 ]. It presents as difficulty or fear of swallowing liquids, foods, or both, in the absence of structural abnormalities, such as neurological deficits or esophageal dysfunction [ 2 , 3 ]. This condition significantly impacts patients’ quality of life, often leading to social withdrawal, malnutrition, and weight loss [ 4 ]. Psychogenic dysphagia is frequently associated with psychological disorders, including anxiety, depression, and post-traumatic stress disorder (PTSD), which exacerbate the fear of swallowing [ 5 , 6 ] Common symptoms include a sensation of a lump in the throat (globus pharyngeus), fear of choking (phagophobia), or complete avoidance of food [ 4 , 7 ]. This case study highlights the story of a 21-year-old woman suffering from a severe fear of eating for ten years, leading to significant weight loss and malnutrition. Extensive medical testing confirmed that her condition was psychological in nature. Given the limited understanding of psychogenic dysphagia, further research is essential to close knowledge gaps and develop strategies to improve prognosis and outcomes for affected individuals. Case Presentation A 21-year-old Palestinian female university student presented with a longstanding and progressively worsening fear of eating, initially triggered by a choking incident at the age of 11. Following this event, she developed intense dysphagia and an overwhelming fear of choking, which persisted for one year before partially resolving. The patient remained asymptomatic for approximately four years; however, at the age of 16, she experienced a severe relapse. Initially, her difficulties were limited to swallowing solid foods, but over time, her dietary restrictions intensified. She began avoiding solid items such as bread and vegetables and transitioned to a liquid-based diet, primarily consisting of soups. Eventually, she resorted to blending and straining food to consume it in liquid form. Despite these symptoms, the patient did not disclose her condition to anyone, and no medical evaluations were conducted during the early stages. She adapted her eating habits by avoiding foods she perceived as challenging to swallow. Over the past five months, her condition further deteriorated, culminating in a fear of swallowing her own saliva. This prolonged dietary restriction led to significant weight loss, with her weight dropping from 55 kg to 46 kg over a two-year period. The psychological impact was profound, causing her to withdraw from university a year prior to presentation. The patient reported daily panic attacks, occurring up to four times per day, characterized by shortness of breath, palpitations, and an intense fear of death. Her medical history revealed a longstanding diagnosis of generalized anxiety disorder. Additionally, she reported a history of insomnia, nyctophobia (fear of the dark), acrophobia (fear of heights), claustrophobia (fear of confined spaces), and misophonia (distress triggered by the sound of others eating). She also experienced significant anxiety when eating alone and developed a compulsive need to drink water with meals. The patient’s family history reveals no significant history of mental illness, except for her sister, who experienced postpartum depression accompanied by eating difficulties. Additionally, a paternal cousin had a period of poor dietary intake attributed to suspected esophageal motility dysfunction, possibly functional in nature. A psychiatric evaluation confirmed a persistent and escalating fear of eating, primarily rooted in a fear of choking, consistent with the diagnosis of psychogenic dysphagia and eating phobia. The patient explicitly stated, 'I’m afraid to eat; I fear I will die,' and was also diagnosed with generalized anxiety disorder and other associated phobias. On examination, the patient appeared thin but otherwise unremarkable. A neck ultrasound was performed, revealing normal results with no solid or cystic masses or abnormalities in the thyroid gland. Multiple complete blood counts (CBC) were normal, as well as liver function tests, including GPT, GOT, total bilirubin (both direct and indirect), alkaline phosphatase, and erythrocyte sedimentation rate (ESR), all of which were within normal limits. Thyroid-stimulating hormone (TSH) levels were also within normal limits. An upper endoscopy and flexible endoscopic evaluation of swallowing (FEES) were performed, both yielding normal results, suggesting no structural or functional abnormalities in the upper gastrointestinal tract or swallowing mechanism. However, the FEES procedure did not result in any significant improvement in the patient’s symptoms, reinforcing the psychological nature of her condition. A swallow study was performed using thin liquid and puree consistencies. The results showed: Oral Phase: Timely and efficient chewing and mashing, no labial escape, and a good oral phase. Pharyngeal Phase: Functional bolus transition, good laryngeal elevation, absence of aspiration during feeding, complete distention and duration of opening at the pharyngoesophageal segment with no obstruction of flow, and complete pharyngeal stripping wave with clearance. Esophageal Phase: Findings indicated type 1 GERD. The swallow test confirmed the patient had a good swallow overall but emphasized the psychological nature of her condition, with a diagnosis of phagophobia. Additionally, the patient began following the International Dysphagia Diet Standardisation Initiative (IDDSI) system for dietary modifications two months ago. The patient has been on a pharmacological regimen for the past three months, including Escitalopram 20 mg, Mirtazapine 30 mg, and Olanzapine 5 mg. Additionally, she took Clonazepam 0.5 mg for one month. She reported a 35% improvement in symptoms on the days she took Clonazepam, while the other medications led to a noticeable improvement six weeks after starting. Currently, the patient reports an overall 40% improvement in her symptoms. Additionally, psychological support, including cognitive behavioral therapy (CBT), was initiated to address her eating phobia and panic attacks. Additionally, she was started on anxiolytic medication, which resulted in noticeable improvement in her symptoms. Follow-Up and Outcomes Initially, the patient was seen weekly as medications and their dosages were tailored to her specific needs. Currently, follow-ups are planned on a monthly basis to monitor her progress and determine if any adjustments to the medication regimen are necessary. In addition to pharmacological treatment, the patient continues to attend weekly cognitive-behavioral therapy (CBT) sessions. She has demonstrated good tolerability to the medications, with no reported side effects, and has adhered well to the prescribed regimen. Notably, she has gained weight, now weighing 52 kg, which she perceives positively. Ongoing monitoring will focus on her overall progress, ensuring continued adherence, and addressing any need for adjustments in her treatment plan. Additionally, the patient is under regular follow-up with a speech-language pathologist (SLP). Initially, she attended daily sessions aimed at practicing eating using the IDDSI (International Dysphagia Diet Standardisation Initiative) system. As her condition improved, these visits transitioned to weekly sessions, reflecting her progress and successful adaptation to the therapy. Discussion Psychogenic dysphagia, classified under Avoidant/Restrictive Food Intake Disorder (ARFID) in the DSM-5, is a multifaceted condition that bridges psychological and physical domains [ 8 ]. It manifests as a pronounced fear of swallowing in the absence of identifiable structural or neurological abnormalities [ 1 ]. Factors such as bereavement, anxiety, depression, and post-traumatic stress disorder (PTSD) are frequently implicated, often compounding the disorder's severity by intensifying eating-related fears [ 5 , 6 ]. This patient exhibited typical symptoms of psychogenic dysphagia, including an intense fear of choking that progressed from difficulty swallowing solids to liquids over a decade [ 2 , 3 ]. Her condition stemmed from a traumatic life event, aligning with reports of abnormal grief reactions associated with eating disorders [ 5 ]. The patient had a history of anxiety, insomnia, nyctophobia, and other phobias, which are well-documented risk factors for developing psychogenic dysphagia. To rule out organic causes, in accordance with the diagnostic criteria for ARFID, which requires the absence of underlying medical conditions [ 7 ], the patient underwent several investigations including barium swallow, upper endoscopy, FEES, and neck ultrasound, all of which yielded normal results. This confirmed the psychological origin of her symptoms. The therapeutic management involved a multidisciplinary approach, including psychiatric evaluation and pharmacological treatment. The prescribed medications included SSRIs, antipsychotics, and anxiolytics, resulting in a 30% improvement in symptoms after three months. Cognitive Behavioral Therapy, coupled with psychoeducation, was crucial in restructuring the maladaptive thinking associated with her eating phobia, leading to a noticeable improvement in her overall condition [ 8 ]. Some studies suggest electroconvulsive therapy (ECT) as a last-resort option when standard treatments fail, emphasizing the need for individualized care plans [ 9 ]. Given the chronic nature of psychogenic dysphagia, long-term follow-up and psychological support are essential to sustaining improvements and preventing relapses. Overall, early diagnosis and a comprehensive, multidisciplinary approach are vital for managing psychogenic dysphagia [ 8 ]. Further research is needed to address knowledge gaps, refine diagnostic criteria, and establish effective treatment protocols to improve patient outcomes. Conclusion Psychogenic dysphagia is a challenging condition that significantly impacts patients' quality of life. This case highlights the importance of considering psychological factors when no organic cause is found. A multidisciplinary approach, involving pharmacological treatment and cognitive behavioral therapy, led to notable improvement in the patient's condition. Early recognition and comprehensive treatment are crucial for better outcomes in psychogenic dysphagia. Further research is needed to enhance understanding and develop effective therapeutic strategies. Declarations Ethics approval and consent to participate: This case report does not require formal ethics approval as per the regulations of the Palestinian Ministry of Health. Written informed consent was obtained from the patient herself and her treating physician for inclusion in this report. Consent for publication: The patient has provided written informed consent for the publication of her case details and any related images. All identifying information has been removed to ensure confidentiality. Availability of data and material: The data and materials used in this case report are available upon reasonable request from the corresponding author. Competing interests: The authors declare that they have no competing interests. Funding: As medical students from Palestine, a low- to middle-income country facing significant political challenges, we do not have access to external funding for this case report. Given the financial constraints in our region, we kindly request a waiver or reduction in the submission fee for this manuscript. Your support in this matter would be greatly appreciated, enabling us to contribute to the medical literature despite the ongoing challenges we face. Authors’ contributions: • Muhammad Suliman Sunkrot: Conceived the case report, acquired data, and drafted the manuscript. • Dr. Iyad Al-Azzeh: Contributed to the interpretation of the data and critically revised the manuscript for intellectual content. • Saja Junaidi: Provided clinical oversight and handled the care of the patient. • Islam Jadallah: Assisted with data collection and manuscript preparation. • Mohammed Saleh: Contributed to the review and editing of the manuscript. All authors read and approved the final manuscript. Acknowledgements: The authors would like to thank Dr. Iyad Al-Azzeh, the treating psychiatrist, for providing the best treatment for the patient and for sharing this rare case with us. His guidance and support were instrumental in preparing this case report. Clinical trial number: not applicable. References Psychogenic Dysphagia: Overview and Clinical Perspectives [Internet]. Sloap.org. Available from: https://sloap.org/journal/index.php/ijhms/article/view/1894 Psychogenic Dysphagia in an Elderly Patient: A Case of Eating Disorder Due to Trauma and Grief [Internet]. Cureus. Available from: https://www.cureus.com/articles/173660-psychogenic-dysphagia-in-an-elderly-a-case-of-eating-disorder-due-to-trauma-and-grief#! Avoidant/Restrictive Food Intake Disorder: An Overview [Internet]. SciVerse ScienceDirect. Available from: https://www.sciencedirect.com/science/article/abs/pii/S027858462030525X?via%3Dihub Globus Pharyngeus and Eating Disorders: A Review [Internet]. SpringerLink. Available from: https://link.springer.com/article/10.1007/PL00009545 Psychological Factors and Eating Disorders [Internet]. PubMed Central. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9946910/ Impact of Psychogenic Dysphagia on Mental Health [Internet]. SpringerLink. Available from: https://link.springer.com/article/10.1007/s40519-021-01227-z Evaluation of Dysphagia with Flexible Endoscopy [Internet]. SpringerLink. Available from: https://link.springer.com/article/10.1007/s00455-021-10289-1 Multidisciplinary Approaches to Psychogenic Dysphagia [Internet]. PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/35108764/ Electroconvulsive Therapy as a Treatment for Dysphagia [Internet]. PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/29198253/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Apr, 2025 Reviews received at journal 08 Apr, 2025 Reviews received at journal 06 Apr, 2025 Reviewers agreed at journal 02 Apr, 2025 Reviewers agreed at journal 31 Mar, 2025 Reviewers invited by journal 31 Mar, 2025 Editor assigned by journal 21 Mar, 2025 Submission checks completed at journal 17 Mar, 2025 First submitted to journal 17 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6100168","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":436377335,"identity":"8318b1e8-16b7-4673-8b03-1d489c0f0c50","order_by":0,"name":"Muhammad Suliman Sunkrot","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYFACHjDJ2AAj+EHchAIStEhIglgJBqRoMTgA4uPRotvee/DTzRwb2Qb+w8ceztxjU2d8fnXihwcGDPL8YgewajE7cy5ZOndbmnGDRFq64YZnaRJmN95ulgA6zHDm7ATsWm7kGAC1HE5skOAxk3xw4DBQy9kNIC0JBrdxajH+nbvtf2ID/xmIFuMZZzf/IKDFDGjLgcQGhhwzyQ1ALQb8vdvw23LmjJl17rZk4zaJtDTJGQeA+AbvNosEAwncfjneY3w7d5udbD8wxCR7Dtjw8/ef3XzzR4WNPL80di1wwAZnSYBVSuBXjgr4D5CiehSMglEwCkYAAAAXe2O1iqQ0+AAAAABJRU5ErkJggg==","orcid":"","institution":"Hebron University","correspondingAuthor":true,"prefix":"","firstName":"Muhammad","middleName":"Suliman","lastName":"Sunkrot","suffix":""},{"id":436377336,"identity":"edf6991b-b309-4e4a-be9f-de51c191e3fc","order_by":1,"name":"Dr. Iyad Fahmi Al-Azzeh","email":"","orcid":"","institution":"Hebron University","correspondingAuthor":false,"prefix":"Dr.","firstName":"Iyad","middleName":"Fahmi","lastName":"Al-Azzeh","suffix":""},{"id":436377337,"identity":"f732c137-d997-47a8-a14c-bbffcb5bec2e","order_by":2,"name":"Saja Zaki Junaidi","email":"","orcid":"","institution":"Hebron University","correspondingAuthor":false,"prefix":"","firstName":"Saja","middleName":"Zaki","lastName":"Junaidi","suffix":""},{"id":436377338,"identity":"e2aea30b-f522-454f-98fb-fe3a0d69ea37","order_by":3,"name":"Islam Jadallah","email":"","orcid":"","institution":"Hebron University","correspondingAuthor":false,"prefix":"","firstName":"Islam","middleName":"","lastName":"Jadallah","suffix":""},{"id":436377339,"identity":"2ced6aac-5ede-4e08-b216-0779db18a613","order_by":4,"name":"Mohammed Saleh","email":"","orcid":"","institution":"Hebron University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Saleh","suffix":""}],"badges":[],"createdAt":"2025-02-24 23:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6100168/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6100168/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79679465,"identity":"11082646-521b-452a-a7fd-9b5f1286ae1c","added_by":"auto","created_at":"2025-04-01 12:37:42","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":67135,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEndoscopic Views: Figure 1A: GE Junction at 37 cm, Figure 1B: \u0026nbsp;Fundus to GE Junction, Figure 1C: \u0026nbsp;Antrum, and Figure 1D: \u0026nbsp;Duodenum (2nd Part)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6100168/v1/736a7fc1ee09ad094a5db995.jpg"},{"id":79678615,"identity":"df7aec4f-9407-49e1-bb0a-ac97e3ba70e0","added_by":"auto","created_at":"2025-04-01 12:29:42","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59148,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEsophagography reveals no structural abnormalities or dysmotility, extending from the upper and middle thoracic esophagus, Figures (2A+2B) to the lower thoracic esophagus and esophagogastric junction, Figures (2C+2D).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6100168/v1/6884fb452327a51d006c3517.jpg"},{"id":79679471,"identity":"97be81ad-0064-45c0-b8fb-dc70a7e7b9d5","added_by":"auto","created_at":"2025-04-01 12:37:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":614832,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6100168/v1/515d9e35-8283-4d22-bc1b-7bcdf32b398c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Fear to Recovery - Psychogenic Dysphagia and Eating Phobia: A Case Report ","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePsychogenic dysphagia is a rare swallowing disorder caused by psychological rather than anatomical or organic factors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It presents as difficulty or fear of swallowing liquids, foods, or both, in the absence of structural abnormalities, such as neurological deficits or esophageal dysfunction [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This condition significantly impacts patients\u0026rsquo; quality of life, often leading to social withdrawal, malnutrition, and weight loss [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychogenic dysphagia is frequently associated with psychological disorders, including anxiety, depression, and post-traumatic stress disorder (PTSD), which exacerbate the fear of swallowing [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Common symptoms include a sensation of a lump in the throat (globus pharyngeus), fear of choking (phagophobia), or complete avoidance of food [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis case study highlights the story of a 21-year-old woman suffering from a severe fear of eating for ten years, leading to significant weight loss and malnutrition. Extensive medical testing confirmed that her condition was psychological in nature. Given the limited understanding of psychogenic dysphagia, further research is essential to close knowledge gaps and develop strategies to improve prognosis and outcomes for affected individuals.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 21-year-old Palestinian female university student presented with a longstanding and progressively worsening fear of eating, initially triggered by a choking incident at the age of 11. Following this event, she developed intense dysphagia and an overwhelming fear of choking, which persisted for one year before partially resolving.\u003c/p\u003e \u003cp\u003eThe patient remained asymptomatic for approximately four years; however, at the age of 16, she experienced a severe relapse. Initially, her difficulties were limited to swallowing solid foods, but over time, her dietary restrictions intensified. She began avoiding solid items such as bread and vegetables and transitioned to a liquid-based diet, primarily consisting of soups. Eventually, she resorted to blending and straining food to consume it in liquid form.\u003c/p\u003e \u003cp\u003eDespite these symptoms, the patient did not disclose her condition to anyone, and no medical evaluations were conducted during the early stages. She adapted her eating habits by avoiding foods she perceived as challenging to swallow. Over the past five months, her condition further deteriorated, culminating in a fear of swallowing her own saliva.\u003c/p\u003e \u003cp\u003eThis prolonged dietary restriction led to significant weight loss, with her weight dropping from 55 kg to 46 kg over a two-year period. The psychological impact was profound, causing her to withdraw from university a year prior to presentation. The patient reported daily panic attacks, occurring up to four times per day, characterized by shortness of breath, palpitations, and an intense fear of death.\u003c/p\u003e \u003cp\u003eHer medical history revealed a longstanding diagnosis of generalized anxiety disorder. Additionally, she reported a history of insomnia, nyctophobia (fear of the dark), acrophobia (fear of heights), claustrophobia (fear of confined spaces), and misophonia (distress triggered by the sound of others eating). She also experienced significant anxiety when eating alone and developed a compulsive need to drink water with meals.\u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s family history reveals no significant history of mental illness, except for her sister, who experienced postpartum depression accompanied by eating difficulties. Additionally, a paternal cousin had a period of poor dietary intake attributed to suspected esophageal motility dysfunction, possibly functional in nature.\u003c/p\u003e \u003cp\u003eA psychiatric evaluation confirmed a persistent and escalating fear of eating, primarily rooted in a fear of choking, consistent with the diagnosis of psychogenic dysphagia and eating phobia. The patient explicitly stated, 'I\u0026rsquo;m afraid to eat; I fear I will die,' and was also diagnosed with generalized anxiety disorder and other associated phobias.\u003c/p\u003e \u003cp\u003eOn examination, the patient appeared thin but otherwise unremarkable. A neck ultrasound was performed, revealing normal results with no solid or cystic masses or abnormalities in the thyroid gland. Multiple complete blood counts (CBC) were normal, as well as liver function tests, including GPT, GOT, total bilirubin (both direct and indirect), alkaline phosphatase, and erythrocyte sedimentation rate (ESR), all of which were within normal limits. Thyroid-stimulating hormone (TSH) levels were also within normal limits.\u003c/p\u003e \u003cp\u003eAn upper endoscopy and flexible endoscopic evaluation of swallowing (FEES) were performed, both yielding normal results, suggesting no structural or functional abnormalities in the upper gastrointestinal tract or swallowing mechanism. However, the FEES procedure did not result in any significant improvement in the patient\u0026rsquo;s symptoms, reinforcing the psychological nature of her condition.\u003c/p\u003e\u003cp\u003eA swallow study was performed using thin liquid and puree consistencies. The results showed:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eOral Phase: Timely and efficient chewing and mashing, no labial escape, and a good oral phase.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePharyngeal Phase: Functional bolus transition, good laryngeal elevation, absence of aspiration during feeding, complete distention and duration of opening at the pharyngoesophageal segment with no obstruction of flow, and complete pharyngeal stripping wave with clearance.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEsophageal Phase: Findings indicated type 1 GERD.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe swallow test confirmed the patient had a good swallow overall but emphasized the psychological nature of her condition, with a diagnosis of phagophobia. Additionally, the patient began following the International Dysphagia Diet Standardisation Initiative (IDDSI) system for dietary modifications two months ago.\u003c/p\u003e \u003cp\u003eThe patient has been on a pharmacological regimen for the past three months, including Escitalopram 20 mg, Mirtazapine 30 mg, and Olanzapine 5 mg. Additionally, she took Clonazepam 0.5 mg for one month. She reported a 35% improvement in symptoms on the days she took Clonazepam, while the other medications led to a noticeable improvement six weeks after starting. Currently, the patient reports an overall 40% improvement in her symptoms.\u003c/p\u003e \u003cp\u003eAdditionally, psychological support, including cognitive behavioral therapy (CBT), was initiated to address her eating phobia and panic attacks. Additionally, she was started on anxiolytic medication, which resulted in noticeable improvement in her symptoms.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eFollow-Up and Outcomes\u003c/h2\u003e \u003cp\u003eInitially, the patient was seen weekly as medications and their dosages were tailored to her specific needs. Currently, follow-ups are planned on a monthly basis to monitor her progress and determine if any adjustments to the medication regimen are necessary. In addition to pharmacological treatment, the patient continues to attend weekly cognitive-behavioral therapy (CBT) sessions. She has demonstrated good tolerability to the medications, with no reported side effects, and has adhered well to the prescribed regimen. Notably, she has gained weight, now weighing 52 kg, which she perceives positively. Ongoing monitoring will focus on her overall progress, ensuring continued adherence, and addressing any need for adjustments in her treatment plan.\u003c/p\u003e \u003cp\u003eAdditionally, the patient is under regular follow-up with a speech-language pathologist (SLP). Initially, she attended daily sessions aimed at practicing eating using the IDDSI (International Dysphagia Diet Standardisation Initiative) system. As her condition improved, these visits transitioned to weekly sessions, reflecting her progress and successful adaptation to the therapy.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePsychogenic dysphagia, classified under Avoidant/Restrictive Food Intake Disorder (ARFID) in the DSM-5, is a multifaceted condition that bridges psychological and physical domains [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It manifests as a pronounced fear of swallowing in the absence of identifiable structural or neurological abnormalities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Factors such as bereavement, anxiety, depression, and post-traumatic stress disorder (PTSD) are frequently implicated, often compounding the disorder's severity by intensifying eating-related fears [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis patient exhibited typical symptoms of psychogenic dysphagia, including an intense fear of choking that progressed from difficulty swallowing solids to liquids over a decade [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Her condition stemmed from a traumatic life event, aligning with reports of abnormal grief reactions associated with eating disorders [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The patient had a history of anxiety, insomnia, nyctophobia, and other phobias, which are well-documented risk factors for developing psychogenic dysphagia.\u003c/p\u003e \u003cp\u003eTo rule out organic causes, in accordance with the diagnostic criteria for ARFID, which requires the absence of underlying medical conditions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the patient underwent several investigations including barium swallow, upper endoscopy, FEES, and neck ultrasound, all of which yielded normal results. This confirmed the psychological origin of her symptoms.\u003c/p\u003e \u003cp\u003eThe therapeutic management involved a multidisciplinary approach, including psychiatric evaluation and pharmacological treatment. The prescribed medications included SSRIs, antipsychotics, and anxiolytics, resulting in a 30% improvement in symptoms after three months. Cognitive Behavioral Therapy, coupled with psychoeducation, was crucial in restructuring the maladaptive thinking associated with her eating phobia, leading to a noticeable improvement in her overall condition [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome studies suggest electroconvulsive therapy (ECT) as a last-resort option when standard treatments fail, emphasizing the need for individualized care plans [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Given the chronic nature of psychogenic dysphagia, long-term follow-up and psychological support are essential to sustaining improvements and preventing relapses.\u003c/p\u003e \u003cp\u003eOverall, early diagnosis and a comprehensive, multidisciplinary approach are vital for managing psychogenic dysphagia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Further research is needed to address knowledge gaps, refine diagnostic criteria, and establish effective treatment protocols to improve patient outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePsychogenic dysphagia is a challenging condition that significantly impacts patients' quality of life. This case highlights the importance of considering psychological factors when no organic cause is found. A multidisciplinary approach, involving pharmacological treatment and cognitive behavioral therapy, led to notable improvement in the patient's condition. Early recognition and comprehensive treatment are crucial for better outcomes in psychogenic dysphagia. Further research is needed to enhance understanding and develop effective therapeutic strategies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u003c/p\u003e\n\u003cp\u003eThis case report does not require formal ethics approval as per the regulations of the Palestinian Ministry of Health. Written informed consent was obtained from the patient herself and her treating physician for inclusion in this report.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003c/p\u003e\n\u003cp\u003eThe patient has provided written informed consent for the publication of her case details and any related images. All identifying information has been removed to ensure confidentiality.\u003c/p\u003e\n\u003cp\u003eAvailability of data and material:\u003c/p\u003e\n\u003cp\u003eThe data and materials used in this case report are available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eAs medical students from Palestine, a low- to middle-income country facing significant political challenges, we do not have access to external funding for this case report. Given the financial constraints in our region, we kindly request a waiver or reduction in the submission fee for this manuscript. Your support in this matter would be greatly appreciated, enabling us to contribute to the medical literature despite the ongoing challenges we face.\u003c/p\u003e\n\u003cp\u003eAuthors’ contributions:\u003c/p\u003e\n\u003cp\u003e• Muhammad Suliman Sunkrot: Conceived the case report, acquired data, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003e• Dr. Iyad Al-Azzeh: Contributed to the interpretation of the data and critically revised the manuscript for intellectual content.\u003c/p\u003e\n\u003cp\u003e• Saja Junaidi: Provided clinical oversight and handled the care of the patient.\u003c/p\u003e\n\u003cp\u003e• Islam Jadallah: Assisted with data collection and manuscript preparation.\u003c/p\u003e\n\u003cp\u003e• Mohammed Saleh: Contributed to the review and editing of the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Dr. Iyad Al-Azzeh, the treating psychiatrist, for providing the best treatment for the patient and for sharing this rare case with us. His guidance and support were instrumental in preparing this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePsychogenic Dysphagia: Overview and Clinical Perspectives [Internet]. Sloap.org. Available from: https://sloap.org/journal/index.php/ijhms/article/view/1894 \u003c/li\u003e\n\u003cli\u003ePsychogenic Dysphagia in an Elderly Patient: A Case of Eating Disorder Due to Trauma and Grief [Internet]. Cureus. Available from: https://www.cureus.com/articles/173660-psychogenic-dysphagia-in-an-elderly-a-case-of-eating-disorder-due-to-trauma-and-grief#! \u003c/li\u003e\n\u003cli\u003eAvoidant/Restrictive Food Intake Disorder: An Overview [Internet]. SciVerse ScienceDirect. Available from: https://www.sciencedirect.com/science/article/abs/pii/S027858462030525X?via%3Dihub \u003c/li\u003e\n\u003cli\u003eGlobus Pharyngeus and Eating Disorders: A Review [Internet]. SpringerLink. Available from: https://link.springer.com/article/10.1007/PL00009545 \u003c/li\u003e\n\u003cli\u003ePsychological Factors and Eating Disorders [Internet]. PubMed Central. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9946910/ \u003c/li\u003e\n\u003cli\u003eImpact of Psychogenic Dysphagia on Mental Health [Internet]. SpringerLink. Available from: https://link.springer.com/article/10.1007/s40519-021-01227-z \u003c/li\u003e\n\u003cli\u003eEvaluation of Dysphagia with Flexible Endoscopy [Internet]. SpringerLink. Available from: https://link.springer.com/article/10.1007/s00455-021-10289-1 \u003c/li\u003e\n\u003cli\u003eMultidisciplinary Approaches to Psychogenic Dysphagia [Internet]. PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/35108764/ \u003c/li\u003e\n\u003cli\u003eElectroconvulsive Therapy as a Treatment for Dysphagia [Internet]. PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/29198253/ \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Case report, Psychogenic Dysphagia, Eating Phobia, Avoidant/Restrictive Food Intake Disorder (ARFID), Phagophobia, Anxiety Disorders, Generalized Anxiety Disorders, Swallowing Disorders","lastPublishedDoi":"10.21203/rs.3.rs-6100168/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6100168/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePsychogenic dysphagia is a rare swallowing disorder with psychological origins, classified under Avoidant/Restrictive Food Intake Disorder (ARFID) in the DSM-5. It often leads to significant social withdrawal, malnutrition, and weight loss, and is commonly associated with anxiety, depression, and PTSD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case involves a 21-year-old Palestinian female who developed phagophobia after a choking incident at age 11. Over time, her fear of choking led to the avoidance of solid foods and a shift to a liquid diet. Her condition worsened, resulting in significant weight loss (55 kg to 46 kg) and severe malnutrition. She also experienced daily panic attacks and had a history of generalized anxiety disorder and other phobias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInvestigation and Diagnosis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComprehensive medical investigations, including neck ultrasound, blood tests, upper endoscopy, and flexible endoscopic evaluation of swallowing (FEES), revealed no structural abnormalities, rolling out organic causes.\u003c/p\u003e\n\u003cp\u003ePsychiatric assessment confirmed a diagnosis of eating phobia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManagement and Outcome:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTreatment included pharmacotherapy (SSRIs, antipsychotics, anxiolytics) and Cognitive Behavioral Therapy (CBT). After three months, the patient reported a 30% improvement in symptoms and dietary intake. Long-term follow-up was recommended.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case highlights the importance of recognizing psychogenic dysphagia as a psychological disorder with physical manifestations. Early intervention with pharmacotherapy and Cognitive Behavioral Therapy can significantly improve symptoms and dietary intake, emphasizing the need for a multidisciplinary approach in managing such complex cases.\u003c/p\u003e","manuscriptTitle":"From Fear to Recovery - Psychogenic Dysphagia and Eating Phobia: A Case Report ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 12:29:38","doi":"10.21203/rs.3.rs-6100168/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-09T07:58:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-08T07:24:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-06T19:57:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234857387689812038619474876923061381940","date":"2025-04-02T05:13:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279465747814459723241363067533454348746","date":"2025-03-31T12:53:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-31T11:57:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-21T07:12:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-17T15:03:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2025-03-17T15:02:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e786d28c-4694-4695-b7b4-36880d24ec4e","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T05:23:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-01 12:29:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6100168","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6100168","identity":"rs-6100168","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}