Choking Phobia in an Older Adult

Critical Overview of the Literature

Choking phobia can be conceptualized as a specific phobia (American Psychiatric Association, 2013). It is associated with the avoidance of swallowing food, fluids, or pills, and is also frequently linked to a fear of choking to death (McNally, 1994). This phobia can impact weight loss and nutrition intake (Franko et al., 1997). Complaints about perceived abnormalities in the esophagus can occur in the absence of physical causes, although the prevalence of this phenomenon remains unknown (Baijens et al., 2013). Choking phobia appears to affect all ages, albeit mostly women, with onset linked to stressful events (Baijens et al., 2013; McNally, 1994). There is a paucity of research in this area, including the lack of data on its incidence, possibly hampered partly by the inconsistent terminology (e.g., swallowing phobia, pnigerophobia, pnigophobia, phagophobia).

The dominant intervention approach to treating choking phobia has been underpinned by behavioral models. A core component involves exposure to the feared stimuli (McNally, 1994). However, there is a lack of standardized protocols and evidence beyond case studies (e.g., Baijens et al., 2013). One exception is recent work to treat avoidant/restrictive food intake disorder (ARFID), a diagnosis introduced only recently that focuses particularly on young people (American Psychiatric Association, 2013). A CBT protocol has been manualized to treat ARFID in children over 20–30 sessions, with the option of involving family members, but trial results await (Thomas et al., 2018).

Despite the higher incidence of choking to death in older age (Kramarow et al., 2014) and the mental health burden of experiencing fear of choking (Baijens et al., 2013; Franko et al., 1997; McNally, 1994), it is surprising that treatments for choking phobia remain little researched in adults above the age of 65. This may be because the problem is positioned between – and perhaps inadvertently overlooked by – different professions, for example, speech and language therapists as well as clinical psychologists, all of whom get referrals for such problems.

Most of the available case studies on choking phobia are either children or working-age adults (McNally, 1994). The oldest person reported to be treated for choking phobia with a psychological approach was aged 69 (Millikin & Braun-Janzen, 2013). Current attempts at psychological treatment innovation in this area do not include older age (Thomas et al., 2018), despite the mounting evidence that CBT can be effective in treating a range of anxiety disorders in older adults (Gould et al., 2012), including via telephone delivery (Brenes et al., 2015; McCurry et al., 2021). While gerontology-enriched formulations have been successfully applied to address anxiety and depression in older people (Laidlaw et al., 2004), the value of this approach in informing the treatment of choking phobia remains unexplored.

The Case

Patricia is an 81-year-old White, British, widowed woman living in southern England. She was referred to the Community Mental Health Team. The GP initially explained that Patricia had persistent sensations of food getting stuck in her throat, and that she, as a result, restricted her food intake primarily to liquids. There were concerns from the GP and her family about her dietary nutrients. She had been prescribed lofepramine for low mood and anxiety and zopiclone for sleeping difficulties.

Initial Assessment

Patricia described her difficulties eating solid food over the past year. She described experiencing sensations that tiny bits of food were getting stuck in her throat, often several hours after finishing a meal. She worried she would choke to death. This worry began about a year ago, when the GP switched her to a new antidepressant. Once the medication had changed, she began to experience high levels of anxiety and panic attacks, including a week when she reported being unable to walk. Patricia reported that in the 1980s she had experienced agoraphobia and struggled to leave the house on her own or take public transport, though she had never received psychological support for it. She also said she had hated hospitals since she was young.

Patricia still thought she had a “medical” problem, despite having undergone appropriate endoscopy and esophagus tests, both of which showed no signs of abnormalities. She was initially hesitant to speak to a psychologist but expressed that she was willing to try.

Regarding risks, Patricia did not report any thoughts of suicide or self-harm. Her choking had been investigated and was being monitored. Her weight was also at an appropriate level, and there were no indications of self-neglect. Her protective factors were her adult children and wider family and her sense that she “must not give up.” She wanted to avoid “going downhill” with aging and was determined to remain independent, to avoid becoming a “burden.”

Face-to-face sessions were not possible because of the safety restrictions imposed by the COVID-19 pandemic during the first national lockdown in the UK. During this period, the mental health of older people in the UK deteriorated, particularly among women and those without partners (Age UK, 2020; Zaninotto et al., 2022). Patricia explained that she only had access to a landline phone but that her daughter Stacey, who “lived in the area,” could support her in accessing therapy by videoconferencing. Stacey later explained that she is “very busy” and would prefer providing only occasional technical support (e.g., printing materials), if needed.

Patricia’s goals were to (1) eventually work toward eating more solid food – an egg sandwich being the final goal; (2) be less apprehensive and have less negative/worrisome thoughts such as “Am I going to be alright?”; and (3) be able to travel with her friend without worrying about food.

Case Conceptualization

Patricia agreed to focus on her ability to eat solid food (goal 1) as the primary treatment target. We explored the possibility that progress on this could benefit the remaining goals by giving her more confidence and a sense of going back to “how she was before.” A formulation was first collaboratively developed to understand the maintenance processes driving choking phobia, which is represented graphically in Figure 1 but shared as a verbal narrative over the telephone.

As an initial trigger, Patricia noticed the sensation of tiny bits of food caught in her throat, even several hours after a meal; at times this could arise out of the blue or instead made salient when she coughs (e.g., after bending over to pick up something). The characteristics of the four psychological systems were then identified. Patricia reported having automatic thoughts such as “I’m going to choke” and “I’m going to die alone” (cognitive); this, in turn, was connected to anxiety and anger (emotional) as well as physical reactions such as neck-tightening and more coughing (physiological). To help ease these sensations, she would use immediate techniques such as drinking water or eating pudding to “soothe” the throat and later techniques such as avoiding solid food altogether, which ultimately reinforced her belief that, otherwise, she would indeed choke. Patricia also delayed medical appointments as she thought these could lead to hospitalization, reinforcing her sense of being “weak” and then becoming a “burden” to her loved ones.

We also explored early and other significant experiences (longitudinal formulation). Patricia recounted a family story to the effect that she was not meant to “survive” and thus was a “lucky” baby. She recalled memories where she thought she would die – she was taken to the hospital at 12 years of age after an accident and felt she was going to be choked by an oxygen mask. Her Dad died young in his 50s. These experiences resulted in her sense of self (core beliefs) being somehow “weak” and “fragile,” resulting in coping approaches such as “I must always be strong” and “I need to keep control.” When her father left the family for another woman, Patricia described having learned to keep all her feelings to herself to protect her mother, and that “asking for help means I’m weak and a nuisance.”

Throughout therapy, the choking-phobia formulation (Figure 1) was placed within the CCF (Laidlaw et al., 2004) to further understand the interrelationships between the broader contextual factors. Because Patricia was born in the 1940s, key beliefs were discussed concerning the stigma of mental health and the presumed “dangers” of talking about emotions, which deterred her from seeking psychological support earlier (cohort beliefs). A recurrent theme in therapy was the ongoing impact of COVID-19, which cast a light on older people’s presumed “fragility” (sociocultural context). Despite being relatively free from physical ailments, Patricia’s choking phobia can be understood as a way to avoid “going downhill,” motivated by her fear of hospitals (physical health). The family context is also important: This was the first time she had lived on her own since her husband’s death, on whom she had relied for practical and emotional support (role transitions). Her adult children were in their early 60s and thus had also come into older age themselves (intergenerational links). On the one hand, Patricia felt isolated and feared “dying alone,” while working hard to avoid being a “nuisance” to others by staying “strong” (rules for living). Later in therapy, we discussed the themes highlighted by this framework with Patricia, which led to a shared understanding of the challenges associated with the cross-sectional interventions and an expanded view of the therapeutic gains beyond the presumed focal problem (see Discussion).

Content of Sessions

Sessions were conducted between May and September 2020, coinciding with a national lockdown and government guidance on shielding older people (BBC, 2020). We offered a total of 15 sessions over the telephone, each lasting 60 min. Homework recording was explained over the telephone and read back to the therapist in the next session. The first two sessions were assessments. Note that one or more topics were relevant in different sessions, in line with the need for collaboration and flexibility based on good practice guidelines (Blackburn et al., 2001). See Table 1 for an illustration of a session.

Table 1 The procedure of an example session

Typical component	Details of session 9
Agenda setting	Agreeing on agenda items and time allocation
Homework review	Review of exposure task to eating sausages (e.g., review of subjective units of distress (SUDs) throughout; duration of the task; number of repetitions achieved)
Additional change methods	Psychoeducation on the possible counterproductive role of safety-seeking behaviors (e.g., drinking water to make food “pass,” which may also heighten any throat-related sensations)
Homework setting	Continue with the exposure task (e.g., bigger chunks of sausages)
	Perform a behavioral experiment of drinking water immediately after an evening meal vs. delaying drinking and then recording the impact on the extent of noticing throat-related sensations and the associated anxiety)
Feedback	Reviewing learning points and therapeutic alliance

Table 1 The procedure of an example session

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Design and Outcomes Measures

Outcome measures were collected at the start, middle, and end of treatment. The CORE-10 (Clinical Outcomes in Routine Evaluation – Outcome Measure, 10 items) was used as an index of general distress (Connell & Barkham, 2007), as required by the service, and has good internal consistency (Barkham et al., 2013). We used the Fear Questionnaire (FQ; Marks & Mathews, 1979) to capture treatment gains for choking phobia (McNally, 1986). The FQ has two subscales concerning a target phobia: (1) an avoidance scale with scores ranging from 0 to 8 and (2) an anxiety-depression scale with scores ranging from 0 to 40. The test-retest reliabilities of these subscales are .93 and .82, respectively (Marks & Mathews, 1979).

Clinical Implications

Placing the CBT formulation within the context of aging and gerontology – through CCF – could be essential not only to guiding the therapeutic progress but also to understanding therapeutic impasses. Choking phobia as a presenting problem can have the allure of being a single, focal problem and thus suggest the choice of a typical CBT protocol using exposure-based approaches. However, its nature and mechanisms remain little researched in older age. The CCF framework can point to potential systemic issues and barriers that may need addressing before CBT-based protocols can achieve their optimal success. Furthermore, this gerontology-enriched framework provides opportunities to consider and reconsider the meaning of treatment success. Future research could examine the potential added value of CCF-based CBT for other mental and physical health presentations where there is a salient “somatic” element in older adults, such as pain or other ailments.

The therapy itself was understood as a behavioral experiment, putting Patricia’s beliefs – of a cohort nature – about the meaning of sharing her inner private experiences to the test. Toward the end, she reported learning that “talking does not make me worse.” This insight allowed Patricia to increasingly experiment with being more open and vulnerable to her adult children, which may suit her well in navigating the pressures and harnessing the resources within her family. As Patricia said, “trouble heard, troubled halved.” These changes at the level of broader conceptualization may have later downstream effects alleviating her choking phobia. Therefore, treatment socialization is key to addressing older people’s fears of therapy. This may include a more extensive assessment with older people as guided by the CCF, special emphasis on developing a trusting safe relationship, and familiarization with the collaborative approach of CBT which may diverge from preconceptions that expertise resides only within the therapist.

Limitations

This single case may not be generalizable to others, and it is impossible to decisively conclude what role the COVID-10 pandemic or telephone work played without comparison with additional cases. The increase in diet variety may not be attributable to just the therapy delivered, as the adjunct medication could have had an effect too. A single-case experimental design with continuous measurements could be used to rule out the natural passage of time by establishing a stable baseline. An additional standardized measure of clinical distress or anxiety could have been considered, given that the CORE-10 did not readily capture a clinical need at the start of treatment, and the FQ needs validation in older adults. Process measures could have strengthened some of the interpretations, such as the role of experiential avoidance. More in-depth approaches to qualitative data could yield further insights into therapeutic gains not captured with quantitative self-report. Ultimately, refining this approach would lead to more controlled studies in bigger samples to extend beyond the single-case methodology that predominates in this area (Baijens et al., 2013; Davis, Reuther, & Rudy, 2013; Evans & Pechtel, 2011; Görmez et al., 2018; Millikin & Braun-Janzen, 2013; Öst, 1992; Scemes et al., 2009).

Patricia’s goals may have also been made more specific under the SMART rationale, which could have clarified what was possible or not possible in therapy earlier on. Further work could have explored imagery techniques (concerning her early memory of traumatic hospitalization) and involved the system to assist with homework, although this was challenging because of the telephone context, the limited number of sessions, and the relative unavailability of the family. Because of service restrictions, follow-up was not possible as clients in this service are discharged once therapy has ended.

Personal Reflection

Working with this case allowed me to understand the role of a psychologist as part of the client’s system. The COVID-19 pandemic impacted all of us. As a therapist, I noticed that my own feelings about the ongoing crisis possibly interacted with those of Patricia and thus impacted therapy. My own beliefs about aging and its “fragility” were put to the test in this work, as I navigated through my sense of closeness to mortality, watching the news, learning about the experiences of loved ones, and ultimately coping with my fears and frustrations about the lockdown and the ongoing uncertainties. I found myself trying hard to hold hope for Patricia while also trying to do the same for myself.

Working through the exposure tasks required challenging Patricia, but I found myself often perhaps being too “lenient” and “overly” empathic to her avoidance of the homework, despite this becoming a pattern throughout therapy. The telephone context may have allowed me to collude with this experiential avoidance, as it gave me fewer resources to contain Patricia’s emotions, given the lack of shared visuals, my restricted possibilities to read her emotional signals, and my own home context where the boundaries between personal and professional spheres had become blurred.

There were also intergenerational differences between Patricia and me. My age was the same as her grandchildren – I was struck by how this seemingly obvious fact become evident to me only toward the end of therapy. I wonder whether this made me see her needs more so than her strengths. Perhaps this partly explained my frustrations at Patricia’s not “getting better” when her avoidance of solid food persisted toward the end of therapy. However, it was important for me to step away from my own expectations as therapist and understand the therapy experience from Patricia’s perspective – one where she challenged her own long-held assumptions about talking about her feelings and experiences with a new language for help-seeking.