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The Fear of Swallowing
A new article in this month’s NHD Dietitian’s magazine highlighted a newly defined mental health and eating disorder – functional dysphagia.
Health and social care professionals may be used to coming across swallowing difficulties in certain diseases, such as in mouth, throat, or oesophageal cancers, stroke, dementia, brain injury and cerebral palsy, where there is a physical or neurological aspect. However, there is increasing awareness that swallowing difficulties may also present with mental health problems.
What is functional dysphagia?
A diagnosis of functional dysphagia is made based on the presence of the sensation of food sticking in the throat, along with the absence of any other causes. Functional dysphagia is now included within the American Psychiatrists Association updated Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Prior to DSM-5, some 50 per cent of patients with eating disorders were classified into a heterogeneous Eating Disorder Not Otherwise Specified (EDNOS) diagnosis which hampered getting appropriate and timely treatment. Thus a newly defined condition termed Avoidant/restrictive food intake disorder (ARFID) was described.
A different kind of eating disorder
Functional dysphagia is included in this new diagnosis, and can be characterised as a fear of swallowing, or an inability to eat or swallow, food. There is generally a fear of choking, gagging or vomiting, but patients diagnosed with functional dysphagia are not preoccupied with their body shape and do not want to lose weight. They may have experienced some traumatic incident that has triggered the phobia. Alternatively, they may have made a peculiar or illogical association in their mind that may cause the development of the phobia.
Prevalence of functional dysphagia is unknown and generally it has been poorly studied. The NHD article used case studies to illustrate the disorder – ‘Ann’ had dysphagia with foods containing fat, triggered by an obese abuser; Brian (normal weight) diagnosed with schizophrenia, could only drink liquids; ‘Cath’ with a diagnosis of bipolar affective disorder with significant anxiety (who was morbidly obese) could only consume 5 foods and 2 drinks without symptoms of gagging and choking.
Such service users may be at high nutritional risk and may have been referred for nutritional intervention for poor appetite, nutritional deficiencies, weight loss and/or anxiety around food and choking issues. Users may present with deficiencies or excess of energy, macronutrients like fat and micronutrients (vitamins and minerals). Nutritional management would seek to minimise health risks and improve quality of life. Motivation to change should be assessed, whilst respecting individual beliefs and wishes. For some, the dysphagia acts as an integral part of their life, helping them to control and manage their emotions. So whilst nutrition is an important part in the care of such users, the responsibility for managing medical risk and psychological therapy is a multidisciplinary team issue.
Ayela Spiro, British Nutrition Foundation – QCS Expert Nutrition Contributor