Multidisciplinary Treatment

of Functional Dysphagia
and Its Subsets
Jaimie Anderson, MS, CCC-SLP, BC-ANCDS

Not for reproduction or redistribution

Disclosures
• Financial
– Salaried Employee, University of South Florida Joy McCann
Culverhouse Center for Swallowing Disorders
• Nonfinancial
– Volunteer, American Speech-Language-Hearing Association
Special Interest Group 2, Neurogenic Communication Disorders
Professional Development Committee
– Volunteer, Academy of Neurologic Communication Disorders
and Sciences Board Certification Committee
– Volunteer, Dysphagia Research Society (DRS) Website,
Communication and Public Relations Committee

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Learning Objectives

1. Examine characteristics of phagophobia

2. Examine characteristics of muscle tension dysphagia
3. Examine characteristics of avoidant/restrictive food
intake disorder
4. Distinguish types of multidisciplinary treatment for
functional dysphagia
5. Reflect on the role of mental health psychology in the
management of functional dysphagia

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 Chapter 1
Subsets of Functional Dysphagia

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Functional Neurologic Disorder (FND)
• DSM-5-TR functional neurologic disorder criteria
– One or more symptoms of altered voluntary motor or sensory
function
– Not better explained by another medical or mental disorder
– Causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning or
warrants medical evaluation
• Inclusionary diagnosis
1. Symptoms are inconsistent with examination
2. Symptoms are internally inconsistent
3. Symptoms are associated with inefficient movement

American Psychiatric Association, 2022

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Rome IV Diagnostic Criteria for
Functional Dysphagia
1. Sense of solid and/or liquid foods sticking, lodging,
or passing abnormally through the esophagus
2. Exclusionary diagnosis
– No esophageal mucosal or structural abnormality
– No evidence of gastroesophageal reflux disease (GERD)
or eosinophilic esophagitis (EoE)
– No esophageal motor disorders
• Criteria must be fulfilled for
– Within the past three months
– Symptom onset at least six months before diagnosis
– Frequency of at least once a week
Aziz et al., 2016
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Possible Subsets of Functional Dysphagia

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Phagophobia

• Intense fear of choking

• Choking or swallowing phobia
• Accompanied by avoidance of swallowing solid food,
liquids, or pills
• In the absence of anatomical or physiological
abnormalities
• Occurs in all ages
• May occur after a choking event (their own or
witnessing another)

Sahoo et al., 2016

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Phagophobia Patient Demographics

• Retrospective review of patients 1978–2005 (n = 41)

found
– More frequent in females (2/3)
– High comorbidity with anxiety disorders
• Panic disorder 41%
• Obsessive conditions 22%
• Separation anxiety 15%
– Antecedents (social)
• Life events (44%)
• Prior traumatic eating life events (56%)

de Lucas-Taracena & Montañés-Rada, 2006

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Phagophobia Case Study
• Middle-aged male
• Problems swallowing solids (meats/bread)
and pills, difficulty initiating a swallow
• Feels like he “locks up” when he swallows
• EAT-10: 28/40
• Onset 16 years ago after taking unspecified
medication
• Strategies: slowing down, chewing well, liquid,
distractions, Xanax (feels it is psychological)
• Reports no issues swallowing in certain
environments
• GI/MBSS stated ”thickened” UES
• To keep the acid down, underwent CP
myotomy; symptoms worsened
• HRM normal: 10% failed, 10% weak, 80% intact;
DCI: 1554 WFL (500–5000)

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Phagophobia Case Example

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“Do Psychogenic Dysphagia Patients Have
an Eating Disorder?”
• Eating Disorder Inventory-2 • Symptom Checklist-90-
(EDI-2) Revised (SCL-90-R)
– PDP (n = 21) were compared
– PDP (n = 21) were compared
to patients with radiographic
to patients with anorexia evidence of dysphagia
(n = 66) (n = 65)
– Lower scores on EDI-2 – Higher scores on
(except maturity fear) interpersonal sensitivity,
depression, anxiety, and
• Conclusion: do not appear to general severity index than
have an eating disorder with patients with dysphagia
• Conclusion: have clinically
significant levels of
psychological distress,
particularly anxiety

Barofsky & Fontaine, 1998

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Different From an Eating Disorder

Phagophobia results in With eating There is a new

the avoidance of food disorders, the main feeding disorder in
or drinks, and ultimately psychopathology is the the DSM-5 called
to weight loss, social constant preoccupation avoidant/restrictive
withdrawal, anxiety, and with losing weight or food intake disorder
depression states fear of becoming fat (ARFID)1

1. Acikel & Ak, 2018

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DSM-5 Avoidant/Restrictive Food Intake
Disorder (ARFID)
• An eating or feeding disturbance, such as
– Apparent lack of interest in eating or food
– Avoidance based on the sensory characteristics of food
– Concern about aversive consequences of eating (e.g., choking,
vomiting, abdominal pain)
• As manifested by one or more of the following
– Significant weight loss (or failure to achieve expected weight gain)
– Significant nutritional deficiency
– Dependence on enteral feeding or oral nutritional supplements
– Marked interference with psychosocial functioning
• NOT due to
– Lack of available food or culturally sanctioned practice
– Disturbance in the way they view their body weight
– Attributable to a concurrent medical condition

Thomas & Eddy, 2019

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Development and Maintenance of ARFID
(Concern for Aversive Consequences)

Biological traits that initially made eating habits a logical choice

Once established, a pattern of food avoidance can become long-standing

Very limited variety or amount of food

Reduced health-related quality of life, weight loss, and reduced nutritional intake

Negative social impact

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ARFID Case Example
• Middle-aged female
• 1.5 years of dysphagia
• During COVID, had three choking episodes and an ER visit; CT neck
was negative
• Stopped eating food for one month, and then once she trialed food,
she had worsening symptoms
• Once food or liquid hits her soft palate, a shock is sent through her
body
• She is not afraid of choking but of this aversive reaction
• Takes five oral supplements per day only, weight stable
• Seen by endocrinology, ENT, gastroenterology, and multiple swallow
studies (FEES and MBSS)
• Trialed PPI, Xanax, and counseling
• OME WFL; EAT-10: 30/40

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ARFID Case Example (cont.)

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Muscle Tension Dysphagia (MTDg)
• Laryngeal muscle tension may be
one of the underlying etiologies in
patients with functional
dysphagia1
• 75% of patients with functional
dysphagia (n = 20) had at least one
type of muscle tension pattern
(MTP) during phonation2
– Type III (n = 13):
anteroposterior shortening
– Type II (n = 5): medial
compression of the false
vocal folds
– Type IV (n = 1): complete
sphincter-like closure of the
supraglottic structures
– 20% had two types of MTP
1. Kang et al., 2016 2. Hamdan et al., 2019
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Muscle Tension Dysphagia (MTDg) (cont.)
• Primary MTDg Diagnostic • Secondary MTDg
Criteria (n = 67) – Presents with
– Symptoms of difficulty concomitant muscle
swallowing ONLY tension–based “irritable
– Significant laryngeal larynx disorders”
muscle tension via • Inducible laryngeal
transnasal laryngoscopy obstruction
• Muscle tension
– No physiological
dysphonia
impairment evident on
• Chronic cough
MBS
• Globus pharyngeus

1. Kang et al., 2016 2. Kang et al., 2021

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Muscle Tension Dysphagia
Patient Demographics

• Prospective study (n = 20)4

– More frequent in females (85.0%)
– 90% White
– 29 to 79 years, with a mean of 54.9 years
– Symptoms for 2–120 months, with mean 35.2 months3
• Prospective study (n = 44 MTDg; 25 control)2
– Higher prevalence of dysphagia (EAT-10 ≥3) in patients
with muscle tension dysphonia (40.9%) in comparison to
subjects with no dysphonia (8%) (p < .005)

1. Kang et al., 2021 3. de Lucas-Taracena & Montañés-Rada, 2006

2. Hamdan et al., 2019 4. Kang et al., 2016
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Case Study: MTD and MTDg
• Middle-aged female
• Graves’ disease status post thyroidectomy 10 years
ago
• Referred by ENT with a normal exam
• Complains of easy vocal fatigue, effortful speech
• VHI: 20/40
• Difficulty swallowing liquids, solids, and pills, a
sensation of food stuck high in her throat, coughing
when swallowing, and difficulty initiating a swallow
• EAT-10: 30/40

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Videostroboscopy of
Muscle Tension Dysphonia

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MBS Showing Muscle Tension Dysphagia

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Chapter Summary
• DSM-5 established diagnostic criteria for functional neurological disorders
• Rome Foundation established diagnostic criteria for functional dysphagia
• Phagophobia differentiates itself with having food/liquid/pill avoidances due
to fear and has increased risk for psychological and social factors for its
etiology
• Avoidant/restrictive food intake disorder (ARFID) is a new DSM-5 term that
classifies food avoidances for different reasons, including fear, and provides
a framework of how food avoidances develop and maintain symptoms
• Muscle tension dysphagia (MTDg) has its own diagnostic criteria that
establish laryngeal muscle tension as an underlying etiology for functional
dysphagia and may co-occur with other irritable larynx syndromes
• These disorders may more specifically describe the patient’s symptoms and
help with identifying patient-specific therapy plans

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 Chapter 2
Multidisciplinary Treatment
for Functional Dysphagia

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Historical Treatment of FNDs
• Supernatural
– Prayer, temple sleep, and
punishment
– Appease the offended divine
entity or pray to another to
receive blessing and relief
• Reproductive organs (hysteria)
– Various perfumes, suppositories,
dietary supplements, or marriage
and conception
– An attempt to return the uterus
to its normal position or appease
the sexual organ through
procreation
Raynor & Baslet, 2021
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Historical Treatment of FNDs (cont.)
• Conversion and dissociation
– Psychodynamic psychotherapy or
psychoanalysis
– Processing painful memories
alleviates symptoms
• Cognitive and neurocircuitry
models
– Behavioral, cognitive, and/or
mindfulness-based therapies;
transcranial magnetic stimulus
– Cognitive reappraisal of somatic
symptoms; decrease in avoided
activities; altering brain networks
directly

Raynor & Baslet, 2021

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Multidisciplinary Treatment

Eye Movement Repetitive

Esophageal Desensitization and Transcranial
Dilation Reprocessing Magnetic
(EDMR) Stimulation (rTMS)

GI Mental Health SLP Behavioral

Medication
Psychology Treatment

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EGD With Dilation
• What? Empirical esophageal
dilation may improve dysphagia
symptoms in patients without
obvious structural lesions.
• Why? Subtle structural lesions
(e.g., small strictures, webs,
rings) could reduce the
esophageal lumen diameter and
be undetected by EGD.
• Retrospective review (n = 27)
showed 62.96% of patients with
unexplained dysphagia had
improvement in their dysphagia
symptoms per Brief Esophageal
Dysphagia Questionnaire.

Zakaria et al., 2017

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Eye Movement Desensitization and
Reprocessing (EMDR)
• What is EMDR?
– Patients briefly focus on their
trauma memory
– Simultaneously, they experience
bilateral stimulation (typically
rapid eye movements)
• Why?
– Associated with reducing the
vividness and emotion associated
with the traumatic memory by
overloading the system
• A case study of a 30-year-old woman
with phagophobia showed a lasting
decrease in symptoms after two
therapy sessions of EMDR

De Jongh et al., 1999

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Repetitive Transcranial Magnetic
Stimulation (rTMS)

• What is rTMS?
– Noninvasive stimulation of specific deep brain regions by
the production of high- and low-intensity magnetic fields
to influence cortical excitability
• Why?
– Literature has shown altered cortical processing in
patients with functional dysphagia compared to controls
– rTMS may facilitate functional connectivity changes
between cortical and subcortical regions to control
movements involved in swallowing disorders

Choi & Pyun, 2021

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Repetitive Transcranial Magnetic
Stimulation (rTMS) (cont.)
• In a case study of a patient with functional dysphagia of 10
years previously treated with medication
• A facilitatory 5 Hz rTMS was applied to the patient’s
supplementary motor area (SMA)
• Functional magnetic resonance imaging (fMRI) showed
brain activation and functional connectivity changes
immediately and three months after rTMS
– Reduction in overactivation of the left-lateralized regions
– Improved connectivity between the left SMA and left precentral
gyrus
• Conclusion: dysphagia symptoms partially improved after
rTMS AND dysphagia rehabilitative program (nonspecific)
Choi & Pyun, 2021
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Medication

• Could be used for treating

anxiety and comorbid
psychiatric disorders
• For functional dysphagia, GI
proposes
– Trial of proton pump inhibitor
(PPI): e.g., omeprazole
– Or tricyclic antidepressants

Aziz et al., 2016

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Medication (cont.)
• In a retrospective review • Case study
of 41 patients with – In the previous case
phagophobia study, a patient with
• Cognitive-behavioral 10-year functional
dysphagia was treated
treatment AND “anti-panic
with clonazepam,
drugs”: alprazolam,
baclofen, trihexyphenidyl,
lorazepam, bromazepam,
and aripiprazole without
imipramine, clomipramine, improvement in
fluoxetine, and paroxetine symptoms2
• Led to a remission rate of
58.5%1
1. de Lucas-Taracena & Montañés-Rada, 2006 2. Choi & Pyun, 2021
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Multidisciplinary Treatment Case Study
• Middle-aged female
• Sensation of food hang up high in the throat and
gagging while swallowing
• Gradual onset a few months prior
• Intermittent episodes of dysphagia and one severe
episode of gagging/choking one month prior
• Downgraded diet to liquids only
• Avoids any social eating (including at home)
• 35-pound weight loss
• ENT, EGD, HRM, TBS, and CT unremarkable

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Multidisciplinary Treatment Case Study
(cont.)

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Multidisciplinary Treatment Case Study
(cont.)

Three speech therapy sessions including biofeedback, surface electromyography,

swallow training, advancement through food hierarchy, and use of relaxation and
breathing exercises

Started Xanax prescribed from physician and used one hour prior to eating BID

Reported reduced anxiety before and during meals and less fear with eating, eats
with family, orders takeout, talks while eating, and is expanding her food choices

Returned for three more sessions targeting advancement of remaining food

avoidances and titration of need for strategies

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Chapter Summary
• Multidisciplinary treatment may include a variety of
modalities, including
– EGD Dilation
– EMDR
– rTMS
– Medication
• Literature is in its infancy and not robust but may be
considered
• Other important professions managing functional GI
disorders include
– Mental health psychology, aka gastropsychology
– SLP

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 Chapter 3
Role of Mental Health Psychology

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Who Is GI Mental Health Psychology?

Riehl et al., 2015

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GI Health Psychology Evaluation
Purpose: identify role of psychosocial factors in patient’s
symptoms and role for behavioral intervention

Demographic and clinical information

Psychosocial checklist to identify current or past stressors

Concomitant treatment form of other medical or psychiatric conditions

Brief Symptom Inventory-18 (BSI-18)

Quality of Life in Reflux and Dyspepsia (QOLRAD)

Psychosocial interview

Riehl et al., 2015

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Helpful Evaluation Questions

Can you tell me your story,

What do you think is going on?
starting at the very beginning?

What do you want help with?

What concerns you? If we could change one thing,
what would it be?

What would you be doing in

Are there other things in your
your life if these
life that are stopping you from
gastrointestinal symptoms
this?
were reduced?

Fikree & Bryne, 2021

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GI Health Psychology Treatment for
Functional GI Disorders

Psychoeducation Lifestyle Advice Arousal Modification

Cognitive Behavioral
Hypnosis (PRN)
Treatment (CBT)

Riehl et al., 2015

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Psychoeducation

What? Goal? How?

• Education about • Psychologist aims 1. Name the medical

medical condition to achieve buy-in condition
and impact of 2. Describe the
impact of
psychosocial
psychosocial
stressors on their stressors on their
symptoms symptoms
3. Identity ways to
reduce stressors
Riehl et al., 2015
Not for reproduction or redistribution
Lifestyle Advice

• Behaviorally modify aspects

of their life to reduce
symptomology
– Exercise
– Dietary modification
– Sleep hygiene
– Increase relaxation
• Phone applications
– Sleepio for sleep
– Headspace for mindfulness
1. Riehl et al., 2015 2. Fikree & Bryne, 2021
Not for reproduction or redistribution
Arousal Modification

What? Goal? When?

• Diaphragmatic • Reduce physiological • Throughout the day,

breathing arousal and increase but especially during
• Guided imagery relaxation symptom flare-ups
• Progressive muscle or stress
relaxation
• Hypnosis

Riehl et al., 2015

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GI Cognitive Behavioral Treatment (GI-CBT)

What? Goal? How?

• Connects how you • Remediate specific • Cognitive

think, feel, and deficits, such as restructuring
behave in the catastrophizing and • Problem-solving
context of GI hypervigilance, that • Worry control
condition can exacerbate
• Over 6–12 sessions symptoms or impact
in 3–4 months with coping skills
home practice
Riehl et al., 2015
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Gut-Directed Hypnotherapy (GDH)

What? Goal? How?

• Relaxation and • Help reregulate the • Offer symptom-

imagery-based subconscious specific
intervention during a
communication suggestions and
voluntary hypnotic
state between the brain target the thoughts
• 7–12 sessions over and gut and feelings the
3–4 months patient has about
their condition

Riehl et al., 2015

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GI Mental Health Psychology Case Study 1
• 18-year-old female with functional dysphagia
• Fluoxetine 20 mg/day (a type of selective serotonin
reuptake inhibitor—SSRI)
• Weekly CBT sessions
1. Psychoeducation about swallowing physiology
2. Counseling: automatic thoughts and cognitive
distortions
3. Exposure therapy: a list of foods that were avoided was
made in a hierarchy
• Conclusion: after eight sessions, the patient could eat
most foods, and her anxiety during meals decreased
Acikel & Ak, 2018
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GI Mental Health Psychology Case Study 2
• 29-year-old female with functional dysphagia
– Counseling: the patient’s feelings that dysphagia is scary were validated
– Psychoeducation: reassured the patient using negative manometry and
EGD
– CBT is used to reframe the perception of symptoms as uncomfortable but
not life-threatening
– Develop coping skills to manage future symptoms of dysphagia
• Relaxation techniques
• Positive self-talk
• Coping statements
• Distractions
– Establish better eating behaviors and self-care
• Conclusion: after five sessions, the patient reported increased
confidence to manage daily stress and esophageal symptoms,
resumed normal eating behaviors, and experienced improved QOL

Riehl et al., 2015

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Cognitive Behavioral Treatment for
ARFID (CBT-AR)

What? Goal? How?

• A novel cognitive 1. Improve nutrition 1. Psychoeducation

behavioral approach 2. Increase variety of 2. Exposure hierarchy
to ARFID foods with increasing
• 20–30 sessions 3. Reduce volume and variety
over six months psychosocial 3. Relapse therapy
impairment

Thomas & Eddy, 2019

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CBT-AR for ARFID:
Fear of Aversive Consequences
1. Provide psychoeducation on how avoidance increases anxiety

Thomas & Eddy, 2019

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Treatment for ARFID: Fear of Aversive
Consequences (CBT-AR)
Subjective Units of
2. Create exposure Distress/
Food or Eating
Situation to Be
hierarchy (food and Temperature on
Tried
Fear Thermometer
environment) 100
3. Continue exposures 90

until the patient 80

70
reaches the goal at the 60
most distressing task 50
on the hierarchy AND 40

without “safety 30
20
behaviors”
10
4. Prevent relapses 0

Thomas & Eddy, 2019

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Summary of GI Health Psychology From
Rome Foundation Gastropsychology
1. Educate on hardware
versus software
2. Reframe and normalize
the process
3. Conscious awareness to
override subconscious
4. Think it differently, and
you can feel it differently
5. It is important to be with a
“safe” person, who can
sometimes be the SLP

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Chapter Summary

• GI mental health psychology, or gastropsychology, is a

key player in multidisciplinary treatment for patients
with functional GI disorders, including functional
dysphagia
• This starts with a comprehensive evaluation to assess
psychosocial factors impacting symptoms
• Treatment includes psychoeducation and arousal
modification and may involve a variety of tools such as
hypnosis and CBT

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Course Summary
• When evaluating a patient for possible functional dysphagia,
you may consider phagophobia, avoidant/restrictive food
intake disorder, and muscle tension dysphagia
• Multidisciplinary treatment may include esophageal dilation,
medication, EMDR, rTMS, and GI mental health psychology
• GI mental health psychology may involve evaluation,
psychoeducation, arousal modification, cognitive behavioral
therapy, and hypnosis
• SLPs can learn from these techniques in their approach to
the management of functional dysphagia, as well as refer
out for additional help

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 Bibliography

MedBridge
Multidisciplinary Treatment of Functional Dysphagia and Its Subsets
Jaimie Anderson, MS, CCC-SLP, BC-ANCDS

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