Introduction
Psychogenic dysphagia is the fear and subsequent avoidance of swallowing in the absence of an organic origin, such as a neurological deficit or physical abnormality (Baijens et al., Reference Baijens, Koetsenruijter and Pilz2013). Psychiatric conditions associated with swallowing complaints include panic disorder, obsessive compulsive disorder, social phobia, anorexia nervosa, globus hystericus, and post-traumatic stress disorder (McNally, Reference McNally1994). In DSM 5, psychogenic dysphagia is classified under the diagnostic category of avoidant/restrictive food intake disorder or specific phobia (2013). Food avoidance or restriction may be based on sensory characteristics, such as appearance, color, smell, texture, temperature, or taste. Food avoidance may also stem from a conditioned negative response associated with an aversive experience, such as choking, repeated vomiting, a traumatic investigation (e.g. esophagoscopy) or witnessing someone else choke (2013). The prevalence of psychogenic dysphagia is unclear but it appears to be more common in females than males, with an onset that can range from childhood to the geriatric population. Patients with psychogenic dysphagia often report comorbid anxiety and/or depression (Bulow, Reference Bulow, Shaker, Belafsky, Postma and Easterling2013). Psychogenic dysphagia is extremely distressing and if untreated will likely lead to weight loss and malnutrition. Hence, early diagnosis and treatment is essential.
Currently, there are no guidelines for managing psychogenic dysphagia. Literature search of psychogenic dysphagia describes case reports using different therapeutic modalities, such as psychoeducation, hypnosis, cognitive behavioral therapy, eye movement desensitization and reprocessing, exposure therapy, and antidepressants (Baijens et al., Reference Baijens, Koetsenruijter and Pilz2013). To date, there are no reports on the use of electroconvulsive therapy (ECT) for treating psychogenic dysphagia in an elderly patient.
ECT has been shown to effectively treat a range of disorders, psychotic and non-psychotic disorders, including depression, bipolar disorder, schizophrenia, catatonia, neuroleptic malignant syndrome, and parkinsonism (Fink, Reference Fink2001). Besides inducing a controlled seizure, the mechanism by which ECT works for the aforementioned vastly different psychiatric conditions remains unclear.
Case report
Mrs. B is an 82-year-old female with a history of anxiety disorder, who over a course of 3 years, developed worsening swallowing difficulties. She initially complained of having to constantly clear the phlegm from her throat, which then progressed to dysphagia and eventually to a fear of swallowing and choking on her saliva. She underwent an extensive workup by a gastroenterologist, otolaryngologist and speech language pathologist that included flexible nasopharyngoscopy, upper GI series, barium swallow and video fluoroscopy. Investigations showed no anatomical or functional pathology to explain her fear/inability to swallow. Hence, it was concluded that the dysphagia was psychogenic in nature.
The geriatric psychiatry team in the community indicated her overall clinical presentation was a patient with severe anxiety with a fear of swallowing because of choking rather than a depressive symptomatology. They managed her symptoms initially with venlafaxine and then augmented with risperidone due to the near delusional nature of her dysphagia at the time, with minimal benefit.
She was admitted to the hospital with a BMI of 16.8, and a G-tube was inserted in order to manage her failure to thrive. Although her BMI subsequently increased to 20.1, her anxiety and fear of choking on her saliva continued to persist. The consultation-liaison psychiatry service in the hospital attempted to manage her symptoms with Mirtazapine up to 45 mg, Duloxetine up to 60 mg, and Olanzapine up to10 mg in addition to lorazepam. Despite this, she had minimal benefit in her symptoms, and additionally developed tardive dyskinesia secondary to the antipsychotics. Due to the side effects and the lack of efficacy of the medications, geriatric psychiatry and the medicine team collaboratively tapered and discontinued all psychotropic medications except Duloxetine, and a trial of ECT was considered to be the best option.
On admission, she was thin and frail with an anxious disposition. During hospitalization, she kept wiping the saliva off her mouth with a tissue. Speech had normal rate and rhythm but when severely anxious it was staccato with one or two word responses. Additionally, at times she had difficulty answering questions due to her anxiety; however, she was able to follow commands. Mood was stated to be “not good” due to her fear of choking on her saliva. She appeared anxiously distressed but not tearful. She denied thoughts of self-deprecation, nihilism, hopelessness, thoughts of guilt, negative self-esteem, or suicidal ideations. She had obsessional thinking of choking on her saliva, which was constant throughout the day with no diurnal variation. She was oriented to person and place but not always to date. She slept well during her hospitalization. She had fair insight as she understood she had a mental illness affecting her physical health. Her judgment was fair as she agreed to a trial of ECT to address her psychogenic dysphagia. She was found to be competent to give informed consent for the procedure as she understood and appreciated the risk and benefits of ECT.
She received bifrontal ECT three times per week. After two sessions, she was eating three meals per day, drinking by mouth, and no longer spitting her saliva out. After six sessions she was ambulating independently using a four-wheel walker to the dining area to have her meals with the other co-patients. She developed a post ECT delirium, at which time her ECT was stopped.
Unfortunately, she experienced a relapse of her symptoms, including a fear of swallowing and anxiety. ECT was re-initiated after obtaining consent, and she received 10 sessions of ECT over 2 months. She had a positive response after several sessions and her symptoms completely resolved after seven sessions. Her fear of swallowing and anxiety resolved. She no longer perseverated on repeatedly clearing her throat, nor experienced a fear of choking on her saliva or food. She independently ate meals orally, maintained her BMI in a healthy range, and was successfully weaned off benzodiazepines that she had used for years. The G-tube was removed when her BMI increased to 20.1 and after she had consistently demonstrated that she could have her meals by mouth. At the time of discharge, she ate and drank with no anxiety or distress, and furthermore she no longer requested lorazepam. She was discharged with maintenance ECT every 3–4 weeks.
There was a significant improvement in her mental status following ECT; she responded to questions appropriately in full sentences with normal rate, rhythm, and volume. There was no latency and thought form was organized with no tangential or circumstantial processes. Her anxiety and fear of choking resolved and she no longer appeared distressed. She walked around the ward, and she socialized with co-patients while having her meals in the dining area. At home she prepared meals, ate her meals routinely, maintained her personal hygiene, socialized with her husband, and watched TV.
With respect to cognition, Mrs. B had mild cognitive impairment in October 2014 based on a Montreal Cognitive Assessment (MOCA) of 22/30 and Kingston Standardized Cognitive Assessment of 77/125. In August 2015 on admission, her MOCA was 14/30, which was deemed to be secondary to malnutrition; subsequently with improved nutrition and ECT therapy, her MOCA improved to 21/30.
Discussion
Mrs. B's most likely diagnosis is psychogenic dysphagia that was delusional in severity, superimposed on a background of a long-standing primary anxiety disorder. Her phenomenology and presentation could also represent involutional melancholia, a diagnosis in DSM I and II. The onset of involutional melancholia in women usually occurs during the menopausal stage with symptoms of depression, anxiety, restless agitation, insomnia, anorexia, weight loss, hypochondriasis, and sometimes somatic or nihilistic delusions (Hirshbein, Reference Hirshbein2009). Hence, it is also possible that she may have responded to ECT because she experienced a prolonged major depressive episode, previously known as “involutional melancholia” that presented predominantly with anxiety and psychosomatic symptoms such as psychogenic dysphagia (Bulow, Reference Bulow, Shaker, Belafsky, Postma and Easterling2013) of a hypochondriacal delusional intensity. This case report shows that when other therapies have failed, ECT may be considered a potential therapeutic modality for psychogenic dysphagia particularly when the lack of oral intake can be life threatening.
ECT may be an underutilized modality of biological therapy in Psychiatry. Some factors contributing to the underutilization of ECT may be the stigma associated with it, and limited knowledge of its effectiveness. ECT is recommended for schizophrenia, depression, mania, Parkinson's disease, and catatonia. There are also case reports showing the efficacy of ECT in managing delusion disorders: erotomanic (Remington and Jeffries, Reference Remington and Jeffries1994), poverty (Shaligram and Choudhury, Reference Shaligram and Choudhury2006), and oral somatic (Ota et al., Reference Ota, Mizukami, Katano, Sato, Takeda and Asada2003; Uezato et al., Reference Uezato2012). This case report demonstrates that ECT may be considered for patients with an anxiety disorder and psychogenic dysphagia. It is also a modality of therapy that is generally well tolerated in the geriatric population (Kerner and Prudic, Reference Kerner and Prudic2014).
In conclusion, psychogenic dysphagia is a diagnosis of exclusion requiring a multidisciplinary approach involving ear nose and throat specialists, gastroenterologist, speech language pathologist, and mental health professionals. Anatomical or neurological causes must be eliminated prior to making a diagnosis of psychogenic etiology, and if other treatment modalities fail, ECT may be an option in specific cases, for example, where the lack of oral intake may be life threatening.
Conflict of interest
None
Description of authors’ roles
T. S. Y. Kim was involved in the care of the patient and wrote the case report. M. Hussain managed the patient, wrote, and edited the case report. T. Munshi managed the patient and edited the case report.
