Psychosomatic dysphagia case study

Background Information

• 32 year old male client.
• 10 year history of swallowing difficulties with solid foods.
• Needs to drink up to 5 glasses of water with each meal.
• No history of chest infections.
• Barium swallow - no abnormalities
• Trialled reflux medications to no effect

Assessment

• No cranial nerve impairments
• No signs of aspiration.
• Some difficulties eating and swallowing a biscuit, characterised by effortful swallowing and a delayed pharyngeal swallow trigger.
• Some muscle tightness/tension around the neck area.
• The client reported that he is under increasing amounts of stress and that he finds it most difficult to swallow when in large groups.
• Anxious about being the last person to finish eating.
• Reported that he feels self conscious because he chews so much.

Hypothesis

• Stress may be causing the client to tighten his pharyngeal constrictor muscles and then have difficulties swallowing large bolus' or harder foods.

Therapy

• Pharyngeal relaxation exercises.
• Relaxation exercises before eating.
• Compensatory strategies: small mouthfulls, informing people that he is a slow eater when in large groups, avoiding certain foods.
• Highlighting good experiences when eating meals and reflecting on them e.g. a staff chistmas meal went well.

Outcomes

• Client was able to reduce his fluid intake when eating meals to around one cup of water.
• Client reported less anxiety/stress when eating.
• The client reported that he is able to swallow most foods.

Therapy resources used:

Pharyngeal muscle relaxation exercises

1. Practice yawning before eating.

2. Chewing gum – imagine you are chewing gum and as you chew it the gum gets bigger and bigger. Start to make larger and larger jaw movements.

3. Head/neck relaxation exercises. Turn your head to your left for 5 seconds, looking over your solder. Repeat turning to the right. Next look up as far as you can for 5 seconds, followed by looking down towards your chest for 5 seconds.

4. Try taking smaller mouthfuls when you are eating.

Relaxation Exercises

Example of breathing technique:

• Breathe in through nose to count of three  - keep the movement gentle, feel your hand rise as your stomach does.
• Hold breath for count of three.
• Slowly & evenly breathe out through mouth to count of four.
• Pause and repeat this three to four times.

Breathing Techniques

·      Try counting your breathing:  Breathe in 1-2-3, hold 1-2-3, breath out 1-2-3.

• Say “STOP” firmly to yourself. Take three deep, slow breaths and then carry on with your activity slower and more calmly.

Physical

• Mimicking the action of shaking a sleeve down – loosens upper limb muscles and appears quite a natural action.

• Stretch your fingers out wide apart – hold – release – pause – repeat.

• Notice your posture and any tension points – consciously, gentle let your muscles soften e.g. shoulders.

Self-affirming phrases:

• I am competent, I can deal with this, I am in control, I feel at peace, I am relaxed
•  
• Creative visualisation – picture a time when you felt calm, remember what it was like.

• Rehearsal – visualise yourself carrying out task, coping calmly using relaxation techniques.

Progressive Muscle Relaxation

The idea behind progressive muscle relaxation is that you tense a group of muscles, hold them in a state of tension for a few seconds and then gently release the muscles back to their previous state. 

The idea behind it is that

in order to ‘relax’, we need to experience, gain control and build our awareness of how our muscles feel when they are tensed and relaxed.