Fear of Swallowing and Choking: Can Anxiety Stop You Eating?

Can't swallow solid food because you think you'll choke? Learn how the fear of swallowing begins, how it affects eating and how it is approached in therapy.

A few months ago, at dinner one evening, a mouthful of chicken you had eaten in a hurry got stuck in your throat. For a few seconds you couldn't breathe; you coughed and the piece came out. Everyone said "Thank goodness you're all right" and the meal carried on. But for you, that evening did not end. At breakfast the next day, your throat tightened before you swallowed the bread. A week later you were eating only soup, yoghurt and purée. Now you chew every mouthful forty times, drink water with every bite, and skip lunches at work by saying "I'm on a diet." This picture may be a fear of swallowing, a little-known condition that nonetheless deeply affects the life of the person who has it. In this article I will look at how choking anxiety begins, why it magnifies itself, and the steps through which it becomes possible to make peace with food again.

What Is the Fear of Swallowing?

The fear of swallowing is when a person experiences intense fear that they will choke, run out of breath or that food will get stuck in their throat while swallowing food, drink or pills. In the literature it is also referred to as "phagophobia" or fear of choking. In some sources, when it noticeably restricts eating behaviour, it may also be considered under the heading of "avoidant/restrictive food intake disorder". Which name is appropriate can only be decided through a professional assessment.

The main point that sets this fear apart from other eating problems is that the person does not have concerns about weight or body appearance. The person wants to eat, gets hungry and misses the foods they love; but the moment of swallowing feels dangerous to them. So refusing food is not a choice but an avoidance born of fear.

Swallowing is normally an action that happens automatically, without our being aware of it. But when attention turns to this movement, just as when we start thinking about our steps while going down the stairs, the fluency breaks down. The throat muscles tense, the mouth goes dry and the mouthful feels "as if it's getting stuck". This feeling, in turn, seems to confirm the fear. In this way the person reads a tension actually created by anxiety as their body's warning "I can't swallow", and approaches the next mouthful even more tensely. The fear often begins with a single event, within a few days; but thanks to this vicious circle it can last for months, even years.

Symptoms of the Fear of Choking

Common signs in people with a fear of swallowing and choking include:

• Avoiding solid foods, especially meat, bread, rice or dry foods
• Eating only liquids, purées or very soft foods
• Cutting food into very small pieces, chewing for a long time, drinking water after every mouthful
• A feeling of tension, tightening, constriction or a "lump" in the throat while eating
• Freezing before swallowing, holding the mouthful in the mouth for a long time
• Being unable to swallow pills or tablets, crushing medicines or looking for a syrup form
• Wanting someone to be present while eating or, on the contrary, eating alone so that no one sees
• Weight loss, weakness, going without certain nutrients for a long time
• Avoiding group meals, invitations and restaurants

Some of these symptoms can also be confused with a physical swallowing difficulty. For this reason the first step of assessment should always be medical.

Why Does the Fear of Swallowing Develop?

A real experience of choking or something getting stuck. The most common starting point is a choking episode experienced by the person themselves or by someone close to them. A fish bone getting stuck in the throat, a sweet going down the windpipe or witnessing a loved one choke during a meal can lead the brain to pair the act of swallowing with danger.

An experience of vomiting or nausea. Swallowing sensitivity can develop after a severe stomach illness, a period of intense reflux or a bout of vomiting. Where it overlaps with a fear of vomiting, the article on emetophobia may feel familiar.

A general tendency towards anxiety and panic. Anxiety can create tension, dryness and a feeling of constriction in the throat area. Someone prone to anxiety may interpret these feelings as "I won't be able to swallow." If you constantly feel as if something is stuck in your throat, the article on the feeling of a lump in the throat may also help explain this experience.

Difficult experiences with food in childhood. Being force-fed, growing up with the rule "you're not leaving the table until you've finished your plate" or tensions at the dinner table can lay the groundwork for associating food with anxiety.

A period of severe stress. During periods such as job loss, grief, moving house or relationship problems, the body's general tension increases. This tension sometimes shows itself at the most sensitive point: the throat.

How Does Choking Anxiety Affect Daily Life?

In Turkey, food is not just nourishment; it is the centre of social life. Bayram (religious holiday) tables, wedding meals, iftar invitations, lunch breaks with colleagues, the plate put in front of you when you visit someone... For someone with a fear of swallowing, each of these can become a separate test.

Let's say you are at a dinner your mother-in-law has prepared. On the table there are mantı (Turkish dumplings), white bean stew, rice and stuffed vine leaves with meat. The question comes: "You're not eating anything, didn't you like it?" You don't want to explain your fear, because you know that if you do, you'll get the answer, "Whoever heard of such a thing, go on, eat, nothing will happen." This well-meant insistence turns into pressure that multiplies the anxiety.

Similar difficulties arise at work. Not joining colleagues for lunch and turning down what is offered in meetings can lead the person to drift away from the team. Some people prefer to eat alone at their desk, in front of the screen, so that no one notices.

In terms of nutrition, the picture can become serious over time. Limited, monotonous eating can lead to consequences such as weight loss, weakness, hair loss and difficulty concentrating. As the person notices these symptoms, the pressure of "I need to eat something" increases; and this pressure makes the moment of eating even tenser.

During Ramadan, iftar tables, crowded family gatherings and long invitations can also bring an extra burden. In these settings, where everyone starts eating at the same moment and dishes keep coming one after another, a person who takes nothing but soup onto their plate easily draws attention. Some make excuses so as not to go to invitations because of this; others go and leave hungry.

Parents face a particular difficulty: a mother or father who worries about passing their fear on to their child may watch every mouthful the child takes with anxiety. Children, in turn, immediately sense the parent's tension at the table.

What Can You Do to Cope with the Fear of Swallowing?

Medical assessment first

To find out whether the swallowing difficulty has a physical cause, see an ear, nose and throat specialist or a gastroenterologist. This assessment should not be postponed especially if you also have trouble swallowing liquids, if there is pain when swallowing, if your weight loss is rapid or if there has been a change in your voice. The absence of a medical problem suggests that the fear is related to anxiety and lays the groundwork for psychological work.

Slow the moment of eating down, but don't turn it into a ritual

Not rushing while eating, eating sitting down and keeping mouthfuls a reasonable size are good habits for everyone. However, behaviours such as chewing every mouthful forty times, drinking water after every bite or adopting a special position before swallowing can, over time, turn into safety rituals that maintain the fear. Try to notice which behaviour is reasonable and which is a ritual born of anxiety.

Move your attention away from your throat

When attention locks onto the throat at the moment of swallowing, it breaks the fluency of the automatic movement. While eating, try focusing on the conversation, or on the taste, texture or smell of the food. Light music or talking with someone next to you can help attention stay more flexible.

Try new textures gradually

Make a list from the food you fear least to the food you fear most. For example yoghurt, milk pudding, soft pasta, boiled potatoes, the soft inside of bread, rice, meatballs, chicken... Starting from the lower steps of the list, take a small step every day. At each step, note how your anxiety rises and then falls.

Relax the body

Doing a few minutes of diaphragmatic breathing and relaxing the shoulder and neck muscles before eating can reduce tension in the throat area. Sitting down at the table with a tense body increases the feelings that make swallowing harder.

Record small successes

Each time you manage to eat a food you find hard to swallow, record it in a short note: what did you eat, what was your anxiety score, what happened afterwards? When anxiety says "you can't", this list becomes concrete evidence of the opposite. Record the days you take a step back too; recovery is not a straight line but a road with ups and downs.

Let your loved ones know

Tell a few people you trust what you are experiencing and ask them not to insist. You can tell them that saying "Eat at your own pace, I'm here" would be more helpful than "Eat, nothing will happen."

Try to keep your nutrition balanced

While working on the fear, take care that your diet does not become overly restricted. Seeing a dietitian can help you get enough nutrients within the textures you find safe. Nourishing soups, purées with yoghurt and vegetables, or fruit drinks are practical ways of supporting your body while the gradual work continues.

When Should You Seek Professional Support?

It is important to talk to a mental health professional in the following situations:

• The fear of swallowing persists even though the medical assessment was normal
• There is marked weight loss or signs of inadequate nutrition
• Your social life, work relationships or family meals are affected by the fear
• You cannot take necessary medication because you cannot swallow pills
• The fear is accompanied by panic attacks, intense anxiety or low mood

If weight loss is rapid and marked, your nutrition may also need to be monitored medically. In that case, psychological work proceeds in cooperation with your doctor and, if necessary, your dietitian. Whether medication is needed can be assessed by a psychiatrist.

How Is the Fear of Swallowing Approached in Therapy?

In the first stage of therapy, how the fear began, which foods and situations are triggers and which safety behaviours are used are assessed in detail. If there is a choking memory, how that moment is remembered is also important; sometimes the memory has been recorded as far more dangerous than the body actually experienced it.

Within the framework of cognitive behavioural therapy, the work usually includes the following:

• Psychoeducation: Understanding how the swallowing reflex works, how anxiety creates tension in the throat and how attention affects this process
• Testing thoughts: Weighing up the evidence for thoughts such as "This mouthful will definitely get stuck" or "If it gets stuck, I'll run out of breath"
• Gradual exposure: With a ladder of steps planned together with the therapist, trying new textures first within the session, then at home and in social settings
• Reducing safety behaviours: Gradually giving up rituals such as excessive chewing, drinking water with every mouthful or eating only in the presence of certain people
• Processing the memory: Working with the choking experience if it has left a traumatic mark

It can also be helpful for a close family member to join some sessions. The effect of insistence at the table, of constant questions like "Have you eaten, were you able to swallow?" or, conversely, of never talking about the fear at all, is explored together, and the shape of support at home is rearranged.

Swallowing is a job your body does without asking you; recovery begins when you can hand that job back to your body.

Progress in therapy is usually seen in small but concrete steps: being able to eat a slice of bread, being able to join a family dinner, being able to order at a restaurant. As these steps accumulate, food can once again become an area of pleasure and sharing. You can find more information about individual work on anxiety on the anxiety and panic page.

Frequently Asked Questions

How can I tell whether my swallowing difficulty comes from anxiety or a physical problem?

Only a doctor can make this distinction. Symptoms such as also having difficulty swallowing liquids, pain when swallowing, hoarseness, rapid weight loss or food coming back up definitely require a medical assessment. If the fear persists even though examinations and tests are normal, the role of anxiety becomes more evident.

Is being unable to swallow pills also part of the fear of swallowing?

It can be. In some people the fear is limited to pills, while in others it also covers food. If you are missing your treatment because you cannot swallow pills, you can ask your doctor whether there are alternative forms, and at the same time work gradually on this fear.

Will taking a first aid course reduce my fear?

Knowing what to do in a choking emergency can reduce the sense of helplessness in some people and strengthen the feeling of control. However, if this information turns into a safety ritual that is constantly reread and rehearsed in the mind at every meal, it can feed the fear. It is more useful to learn the information once and then return to your life.

Is the fear of swallowing an eating disorder?

This fear differs from eating disorders in which concerns about weight or body image are to the fore. However, when it noticeably restricts eating behaviour and affects nutrition, it can also be assessed within the framework of feeding and eating problems. The correct name is given through a detailed professional assessment.

• #fear of swallowing
• #fear of choking
• #phagophobia
• #eating anxiety

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Eda Erkan Alapala

Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.

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