Fear of Choking

What gets eaten and what does not

The restriction is mostly about solids, and the gradations are finer than that suggests:

• most people with it manage semi-solid or soft food
• some can eat solids only when properly lubricated, or only in small pieces
• some cannot swallow tablets
• some are afraid of liquids

Eating in restaurants and other social settings is avoided, because eating in small bites or with liquid after every mouthful is visible. Weight loss follows, and anxiety, depression and social withdrawal follow that.

The condition occurs in children and adults and is reported as equally common in men and women, which is rare enough in this catalogue to be worth noting: most fears with any figure attached to them are reported more often in women.

How it builds

The suggested origin is usually an episode of genuinely choking on food. What follows is described as progressive rather than sudden: swallowing becomes mentally linked to choking, preoccupation with that link grows, and the anxiety eventually becomes a constant presence whenever food is being eaten.

The account given is a feedback loop with its own momentum. Fear produces attention to swallowing, attention makes swallowing feel difficult, and the difficulty confirms the fear until the anxiety is strong enough to generate psychosomatic choking symptoms on its own. At that point the person has evidence.

What the cleft palate study found

The one controlled piece of work in the material is Di Scipio and Kaslon's study from 1982, and it is worth setting out because it identifies a mechanism rather than a correlation.

They examined children within a year of surgery for cleft palate, using a thirty-two item questionnaire about eating, including taste aversions, and compared them with their siblings and with a separate control group. The same questionnaire went to adults familiar with the children's eating habits. Children who had undergone surgery scored higher for feeding difficulty than either control group, and the items that separated them most were small bites, has to be prompted, requires assistance, and does not finish.

The conclusion was classical conditioning in the Pavlovian sense. Physical damage during surgery, intrusive diagnostic procedures, and vomiting or poor suckling beforehand had been paired in time with swallowing, and the conditioned response was a refraining from it.

What aversion relief therapy involves

The treatment section contains something no other entry in this catalogue does. Aversion relief therapy is described as commonly used and proven effective for choking phobias, and the procedure is that the patient is given a small shock to the fingers, continuing until they swallow. Relief arrives only through swallowing, since the shock stops when the action occurs.

That is an aversive conditioning procedure being applied to a condition the same source explains as the product of aversive conditioning. It is recorded here as the material presents it, and a reader encountering the phrase elsewhere should know what it denotes.

The other approaches listed are more familiar and more recent in feel: cognitive behavioural therapy, hypnotherapy, eye movement desensitisation and reprocessing, relaxation before meals with visualisation and breathing work. Whitehead and Schuster described the use of tongue depressors placed at the back of the throat in 1958, so the patient can work against the anxiety directly.

Low doses of selective serotonin reuptake inhibitors have been used, though behavioural approaches are described as more common. Because the condition tends to arrive with other anxiety conditions, generalised anxiety disorder among them, the recommended order is to address those first and the choking fear afterwards.

What travels with it

Fear of choking is associated with anxiety, depression, panic attacks and hypochondriasis, alongside the weight loss. Quality of life is described as severely affected, which for a fear whose object is a routine involuntary action several thousand times a day is not surprising.