Definition

Swallowing Vincibility Syndrome (SVS) is a term coined by the author to describe a person’s mistaken but powerful belief that his or her swallowing mechanism is fragile or does not work, when in fact it is working well, or well enough. And so to say it another way:

It is a psychological or functional disorder in which an individual loses confidence in their ability to swallow safely, comfortably, or normally—despite normal or near-normal anatomy and swallowing physiology.

This loss of confidence may lead to avoidance of eating, restriction of dietary choices, or insistence on eating alone.

Core Features

• Subjective fear that swallowing is unsafe or that it may result in choking, aspiration, discomfort, or embarrassment.
• Normal findings on structural and functional evaluation of swallowing (e.g., no significant pooling, laryngeal penetration, or aspiration during videoendoscopic swallow study (VESS) or videofluoroscopic swallow study (VFSS). In other words, objectively normal swallowing function.
• Often precipitated by a single frightening event (e.g., choking, illness, panic episode) or prolonged stress.
• Self-reinforcing cycle of fear, avoidance, and hypervigilance around swallowing.

Distinction from Organic Dysphagia

Unlike mechanical, neurologic, or inflammatory causes of dysphagia, SVS involves a lack of correlation between symptom severity and objective findings. Patients may describe their symptoms in dramatic or global terms (“I can’t swallow anything”), but again, testing reveals normal or near-normal anatomy and physiology.

Similar Terminology That May Be Found Elsewhere:

• Psychogenic dysphagia
• Phagophobia (fear of swallowing)
• Avoidant/Restrictive Food Intake Disorder (ARFID – fear-based type)

Clinical Presentation (Symptoms)

• Hesitancy or ritualized behavior at mealtimes
• Preference for pureed or liquid diets
• Excessive throat-clearing or “test swallows”
• Anxiety, particularly around social eating
• Physical symptoms such as throat tightness or breath-holding without a physiologic correlate

Pathogenesis

The syndrome seems to develop after a triggering incident and is sustained by anxiety, swallowing hyperawareness, and the ongoing sense that swallowing is “dangerous.”

Management

• Reassurance after thorough diagnostic workup to rule out organic disease.
• Review with the patient of video examinations of his or her swallowing (VESS or VFSS, or both).
• Visual feedback (the patient watches him- or herself eat in real time during VESS). This provides visual proof…
• Swallow desensitization therapy with a speech-language pathologist: “Gentle Swallowing boot camp.”

Prognosis

With a clear (non-waffling) diagnosis and a direct explanation to the patient, along with possible help of a speech pathologist, patients can often recover confidence surprisingly rapidly and resume normal eating. Left unaddressed, however, SVS can evolve into social isolation, nutritional compromise, or a sense of helplessness around swallowing.

Analogy to Vocal Vincibility Syndrome

Like its vocal counterpart, Swallowing Vincibility Syndrome involves a psychologically driven avoidance pattern and overestimation of danger. In both, the individual becomes afraid of a basic physiological function, and in so doing, may unwittingly self-sabotage and reinforce the sense of that function’s vincibility.

What SVS is not

Actual dysphagia (with pooling, aspiration, antegrade cricopharyngeal dysfunction, retrograde cricopharyngeal dysfunction with excessive GI discomfort, etc.) Each of those is described elsewhere on Laryngopedia.

Case Reports

Patient 1

A 30-something man came in for evaluation of his swallowing. He said that more than a year earlier, he had been eating Thanksgiving Dinner with a large group of family and friends. He suddenly choked on something he was eating. The room went silent and all eyes were fixed on him, he said. While he didn’t need a Heimlich maneuver or other intervention, he did cough quite hard for a minute or so, with people patting him on the back, offering water, etc. Ever since that event, he said he had eaten alone for fear this might happen again.

On videoendoscopic evaluation, his “equipment for swallowing” – cheeks, tongue, palate, pharynx, and larynx were perfectly normal anatomically and neurologically. There was no hypopharyngeal pooling of saliva. When he was administered blue-stained applesauce, an orange cracker, and blue-stained water, even in rapid pressured fashion, he performed flawlessly.

He was reassured, and considerable time was spent showing him models, and his video taped VESS procedure. He was asked to bring lunch to his next appointment with a speech pathologist. He was explained that he would eat an entire meal in front of her; she would encourage but would not let him back away until he had eaten the entire meal. He did this a second time to regain his confidence and thereafter, he resumed social eating.

Patient 2

A 38-year-old man said he had been napping and wakened with a buzzing sound in his ear, and felt briefly like he couldn’t swallow. From that time to the initial visit (more than 6 months later), he said he had eaten “nothing but mashed potatoes.” He said no solid food had passed his lips during that entire time. Even though he was already slender, he had lost 15 pounds.

On examination, he was noted to have very poor dentition and mentioned that dental implants were scheduled for the near future. But he insisted that there was no change in his dentition to explain his difficulty, and even though he had few residual teeth, he said he had no trouble chewing and rejected an initial suggestion that maybe difficulty chewing was part of the problem. “But my teeth were the same before this happened,” he said.

At the clincian’s request, he came for a second visit with a “chicken wrap” and ate it during a long VESS procedure. That VESS video was reviewed in detail to show moments when lettuce, chicken, etc. filled the vallecula just before a swallow cleared it completely away. Up to that point he looked overly-serious and even a little bit wide-eyed and anxious. After this extended visit and VESS review, he broke into a smile of relief.

Patient 3

A middle-aged woman was evaluated due to her longstanding swallowing problem. She said that for the past 20 years, she had refused to eat anywhere but at home. This was because 20 years earlier she had a choking event in a public setting. She had even tried unsuccessfully to eat sitting in her car on the driveway. It just made her too anxious to eat anywhere other than at home.

Videoendoscopic swallow study showed normal anatomy and individually elicited movements of tongue, palate, pharynx, and vocal cords. But during food administration, one could see good closure of the vocal cords and then a split-second opening of the glottis just as swallowing was occurring. This was theorized as a disorder of swallow sequencing, with an analogy made to a tongue thrust when eating. The patient practiced making a guttural sound continuously, creating glottal stop sounds, and Valsalva breath-holding while swallowing. The idea was to make glottic closure conscious and not automatic like it would be in the general population.

There was much review of the VESS recording to make sure the patient understood the problem and the need to figure out how to close the vocal cords continuously during each swallow. After considerable practice, the patient began eating in restaurants. Initially, this was always seated with her back to other diners. Progressively, she gained confidence and mastery of her split-second glottal opening at the moment of swallow.