Phagophobia in A 6-Year-Old Child : Case Report

: Introduction : Photophobia or swallowing phobia is a rarely studied clinical entity. Classified as a specific phobia by the DSM-V. Through our clinical case, we highlight the diagnosis difficulty of this clinical entity and the interest of early therapeutic management appropriate to the age of the child. Clinical observation : A 6-year-old female patient was hospitalized in pediatric surgery for esophageal caustic stenosis that required esophageal replacement. Thereafter, the persistence of swallowing disorders was observed while the organic etiological assessment was negative. Manifestations of phobic anxiety were identified starting the first psychiatric consultation. These manifestations were found to be linked to the memory of traumatic events that the patient experienced during the gastro esophageal fibro copy. The diagnosis of phobic disorder was retained and the treatment was essentially based on behavioral therapy. The evolution was globally favorable. Discussion: Photophobia, or swallowing phobia, is an uncommon phobic disorder listed in the 11th edition of the International Classification of Mental Disorders and the DSM-5. The important question before diagnosing this disorder is to determine its psychogenic basis. In most cases, the onset of the disorder follows a swallowing accident, which leads to swallowing phobia, which in turn is considered a particular form of post-traumatic stress disorder. It can also be associated with separation anxiety in children as in our case. Conclusion: Swallowing phobia is considered a specific, non-developmental phobia. Swallowing phobia and other childhood anxiety disorders are closely correlated. Cognitive behavioural therapies have shown favourable responses in most cases.


Introduction
Although the first descriptions of the disorder in children date back to the 1940s, phobia of swallowing or phagophobia remains a poorly studied clinical entity of unknown prevalence [1]. The DSM V-R [2] classifies phagophobia as a specific, nondevelopmental phobia, of which the occurrence is favored by the presence of other pre-existing anxiety disorders. The main consequence of phagophobia is food refusal, which can lead to malnutrition and, in the long term, to serious damage to the child's vital organs [3]. Early diagnosis and appropriate therapeutic management are fundamental for the prognosis. Through our case report and its discussion, we shed light on this clinical entity and the interest of psychological preparation of children before performing an invasive procedure.

Clinical vignette
The female patient H., aged 6 years old, was hospitalized in pediatric surgery for esophageal caustic stenosis due to an accidental ingestion of hydrochloric acid with dysphagia and choking accidents during feeding attempts. After esophageal replacement, by inverted gastric tube, and a postoperative fibroscopy showing a permeable esophagus of good caliber, the swallowing disorders persisted. Given the negative organic etiological assessment, a psychiatric opinion was requested.
The patient had no particular personal or family history, she was the result of a desired pregnancy, well monitored, carried to term, well adapted to extrauterine life and had good psychomotor and psychoaffective development. The patient has not been schooled yet. Since the first consultation, the patient presented manifestations of phobic anxiety: separation anxiety "refused to remain alone during the consultation, had a crying fit , showed clingy behaviors towards her father ", social anxiety "fear of strangers, avoidance", fear of the hospital and medical staff. Moreover, the mother reported that H. chewed the food during meals without swallowing it. When asked what might happen to her, H. clearly expressed her fear of pain or choking when swallowing. www.cmhrj.com After several consultations, these manifestations were linked to the memory of a previous traumatic event that the patient experienced during her hospitalization: the gastro-esophageal fibroscopy. This memory was triggered by each swallowing reflex. Meanwhile, the manifestations of anxiety increased each time the parents forced H. to eat: crying fit, refusal to speak, isolation, insomnia on falling asleep, nightmares, secondary enuresis. Henceforth the child refused to swallow all solid and liquid foods. She was fed exclusively by nasogastric tube. The diagnosis of phobic disorder: separation anxiety, social phobia, simple phobia (swallowing phobia, nosocomephobia) was retained.
The treatment of these disorders, throughout five months, was as follows: A systematic desensitization, considering the importance of the consequences linked to the swallowing phobia and given the age: information on the physiology of swallowing with diagrams and drawings adapted to the patient's age; progressive reintroduction of food. Also, an assertiveness therapy was implemented, in order to help her improve her autonomy and develop more satisfactory social behaviors. The evolution of this child was globally favorable. Her entry into kindergarten and her adaptation to her peers seemed quite satisfactory. During consultations, H. remains alone with her doctor without the presence of one or more parent. She also shows much more autonomy. As far as food is concerned, H. now swallows liquid food in a completely normal way. However, difficulties persist when swallowing some solid foods (bites of bread, meat). During the last consultation, the patient regained weight with a jovial contact and good social interactions.

Discussion
Phagophobia, or phobia of swallowing, is an uncommon phobic disorder mentioned in the 11th edition of the International Classification of Mental Disorders and DSM-5 in its revised version. Swallowing phobia can be defined as the fear of swallowing, choking, or choking on solid or liquid foods, in the absence of physiological or anatomical abnormalities. This fear may be expressed explicitly, or may be expressed through avoidance or reassurance behaviors, crying, anger, or oppositional behaviors at mealtime or during meal preparation [3,4]. In our patient's case, this fear was explicit.
Phagophobia can be severe enough to be life-threatening. It can lead to significant weight loss and malnutrition resulting from avoidance of feeding. Weight loss is progressive, variable and not proportional to the duration of the disorder [4]. In order to prevent a nutritional deficiency in H.,a nasogastric feeding tube was placed as soon as the food refusal was absolut. It is crucial before establishing this diagnosis to determine its psychogenic basis, after excluding all the organic causes must be excluded. Firstly, a complete history is examined, then physical and neurological evaluations are performed and, if necessary, appropriate instrumental studies are completed [4].
Indeed, our psychiatric intervention for H. occurred after an organic etiology was ruled out. This disorder may sometimes be considered a form of anorexia nervosa, however, swallowing phobia is distinguished by the absence of abnormal cognitions and premorbid preoccupations with weight and/or body shape [5]. Although it may precede or accompany the onset of genuine anorexia nervosa, studies have shown that it cannot be equated with an eating disorder [5]. Moreover, in approximately 60% of cases, swallowing phobia in children is associated with other anxiety manifestations, which raises the question of its relationship with other anxiety disorders of childhood [6]. Indeed, the anxiety manifestations were predominant in our patient's case. In most cases, the onset of the disorder follows a swallowing accident in the patient himself or in a relative, which has led some authors to consider swallowing phobia as a particular form of post-traumatic stress disorder [5]. The clinical picture presented may in fact be, reminiscent of a post-traumatic stress state: a reliving syndrome, "sleep onset insomnia, nightmares, secondary enuresis", avoidance and loss of usual interests. However, these symptoms were not constant.
In addition, H. had separation anxiety. Authors have shown that swallowing phobia is often associated with separation anxiety in children. It may be pre-existing or favored by the traumatic event at the origin of the phobia [5]. Other authors consider that separation anxiety plays the role of a facilitating agent, which explains the rapid conditioning of the swallowing phobia on which anxiety about death and separation gets anchored [1]. As for the therapeutic management, the behavioral therapy used with our patient associated with assertiveness techniques and social skills training were sufficient to improve her clinical situation. In the literature, behavioral therapy for the treatment of phagophobia is the most commonly mentioned [7][8]. However, several other treatment techniques have been described as well as their combination: psychoeducation, exposure therapy, hypnosis and rarely an isolated pharmacological approach [9][10]. Solution-focused therapy has also been shown to be effective, particularly when the onset of the disorder is related to a traumatic or upsetting swallowing incident such as vomiting or choking [11]. Furthermore, in 2021, authors demonstrated that the age-appropriate EMDR technique can effectively resolve the dysfunctional symptomatology of a case of phagophobia, within one month of its occurrence [12].
As for the pharmacological approach, we did not resort to the prescription of a drug treatment considering the age of our patient. Behavioral therapy was sufficient to obtain clinical improvement. Moreover, few studies have shown their effectiveness against phagophobia [13].
This clinical case illustrates the importance of psychological preparation of children during invasive procedures. This prevention helps to avoid the development of anxiety disorders in early childhood. On the other hand, although swallowing phobia is an infrequent clinical entity, its nutritional repercussions, sometimes vital, incite us to evoke it during a dysphagia in the aftermath of a swallowing accident. In particular, in the absence of a clear organic disease.

Conclusion
Swallowing phobia is considered a specific, nondevelopmental phobia, which occurs as a result of swallowing accidents. All studies show that the symptoms defining swallowing phobia and other childhood anxiety disorders are closely correlated, which may explain their frequent association in the same patient, but which also raises the problem of their diagnosis limits. Identifying this disorder is crucial since the response is favorable to known specific therapeutic strategies, in particular, cognitive and behavioral therapies.

Declaration of competing interest
All authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence this Work.

Funding sources
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