D y s p h a g i a 7:138-141 (1992)
Dysphagia ,~ Springer-Ver|agNew York Inc. 1992
Systematic Desensitization of Oral Hypersensitivity in a Patient with a Closed Head Injury Gary E. Brown, Ph.D., ~ Sharon Nordloh, M.A., z and Arlene J. Donowitz, M.D. 2 JU n i v e r s i t y o f T e n n e s s e e a n d 2Cane Creek Center, R e b o u n d , Inc., Martin, Tennessee, U S A
Abstract. A 36-year-old man who had sustained a closed head injury displayed extreme fear of being stimulated in the oral cavity, of being presented with foods, and of swallowing. The patient's fear increased his muscle tone and hypersensitivity in the facial and oral area, thereby preventing assessment of his dysphagia. We describe the use of systematic desensitization to alleviate the patient's fear thus allowing successful completion of a videofluoroscopic barium swallow examination. Key words: Systematic desensitization -- Fear of swallowing -- Deglutition -- Deglutition disorders.
Wolpe [ 1] introduced systematic desensitization as an empirically derived clinical procedure for reducing fear and anxiety associated with specific situations. Since its introduction, variations of the procedure have been developed. These modifications rely on one or more of the three components in the traditional systematic desensitization procedure: (a) teaching the patient progressive muscle relaxation; (b) developing a hierarchy of imaginary scenes or real-life situations that elicit progressively greater levels of fear or anxiety; and (c) pairing relaxation with the least fear- or anxiety-eliciting scene (or reallife situation) in the hierarchy until the anxiety or
Address offprint requests to: Gary E. Brown, Ph.D., University of
Tennessee, Martin, TN 38238-5059, USA
fear disappears--and then proceeding through each item in the hierarchy in a similar fashion. In the behavior therapy literature there are occasional reports on the successful use of systematic desensitization and related behavioral procedures in treating patients who have developed dysphagia following traumatic events. In these cases fear and anxiety elicited by a traumatic event cause some type of swallowing difficulty. The specific symptoms reported vary from case to case, with throat constrictions, a tightness in the throat, a lump in the throat, or a tickling sensation in the throat being the most common. Typically, the patient's anticipatory anxiety about reoccurrence of the swallowing difficulty elicits further swallowing difficulties, and a vicious circle of chronic dysphagia is established involving classical and operant conditioning processes. For example, Kaplan and Evans [2] used desensitization and anxiety-reducing instructions to alleviate dysphagia and a phobia of eating in public in a 29-yrold woman. Her swallowing difficulties originated when she was eating out with her husband, and a gunfight erupted in the restaurant. Although she was not hurt physically, the fear and anxiety associated with the incident caused throat constrictions that led to the development of her dysphagia and her phobia of eating in public. No pharyngeal pathology nor evidence of other etiological factors were found in a physical examination. The dysphagia conditioned by traumatic events is often accompanied by phobias, especially choking phobias. McNally [3] used gradual exposure to a hierarchy of fear-eliciting foods to treat a 30-yr-old man who had developed a fear of choking whenever
G.E. Brown et al.: Systematic Desensitization of Oral Hypersensitivity
certain foods tickled his throat. He denied difficulties in swallowing, but chewed excessively before swallowing. In addition, he chose soft foods such as noodles and ice cream that would not tickle his throat. When he was 16 years old the patient panicked when he choked on a piece of fish. Vicarious conditioning may have sensitized him before this choking incident--although he was not present, his best friend had choked to death on a hot dog several years earlier. Solyom and Sookman [4] used desensitization, tongue exercise, and negative reinforcement to treat three patients with dysphagia and choking phobias. Although fear and anxiety elicited by traumatic events had conditioned dysphagia and choking phobias in all three cases, other possible etiological factors were also reported. All three patients were hypochondriacal, had obsessive personality traits, overprotective mothers, and one or more family members with multiple phobias; one patient had a sister with dysphagia. The three patients also had high anxiety levels when the association between the traumatic events and swallowing difficulties was acquired. There are also reports in the behavior therapy literature on the successful treatment of patients who are unable to swallow pills [5] and patients who have developed overactive gag responses to dental treatment [6]. In the present case, a patient's closed head injury had caused abnormal muscle tone and hypersensitivity in the face and oral area. Fear and anxiety related to being stimulated in the oral cavity, being presented with food or liquids, and swallowing developed in the course of the patient's rehabilitation and caused further increases in muscle tone and hypersensitivity. The patient was unable to enjoy a normal diet and the speech language pathologist could not assess the patient's dysphagia using videofluoroscopic barium swallow procedure [7].
Case Report A 36-yr-old man was admitted to our facility approximately 15 months after sustaining a closed head injury in an automobile accident. On admission to the acute care facility he was resuscitated and intubated. The initial computed tomography (CAT) scan revealed intracerebral hemorrhage involving the right cerebrum and the sylvian fissure warranting emergency right frontal ventriculostomy. A lacunar infarct o f the right caudate nucleus was also noted, but there was no abnormality of the cervical spine. Two weeks later the patient underwent a tracheostomy which was later removed, and 3 months later he had a feeding gastrostomy (G) tube placed. Following these procedures he was trans-
139
ferred to the rehabilitation unit of the hospital for coma stimulation. The patient remained in this unit for 4 months. He was then transferred to a head trauma rehabilitation facility where his hypersensitivity and increased facial muscle tone were treated by daily facial massage and intraoral stimulation [8]. All nutrition was provided via a G-tube. A second CAT scan of his head 14 months following his injury showed encephalomalacia of the left temporal and frontal area secondary to cerebral atrophy, a lacunar infarct of the right caudate nucleus, right thalamic atrophy, and an infarct o f the right periventricular white matter. Ten months later, the patient was transferred to our head trauma rehabilitation facility. On initial evaluation he was awake and alert, with his eyes open and wandering. He was able to track visually to the right only. The patient was spastic quadriplegic with marked increased tone, worse on the left than on the right. In addition, he was found to be extremely sensitive to touch on his face, gums, and tongue. He had increased muscle tone whenever anything was placed in his mouth, an uncontrollable bite reflex, and severe dysphagia; he also required suctioning of saliva. A videofluoroscopic study was attempted, but when the oral preparatory stage was initiated, the patient demonstrated increased muscle tone that interfered with proper positioning and therefore the initiation of normal oral transit. Once a delayed swallow reflex was initiated the patient's vigorous reflexive coughing prevented viewing of the swallowing process and completion of the study. Daily facial massage and intraoral stimulation of the patient's face, gums, and tongue were continued for the next 4 months along with his other therapies. The patient's medical status improved markedly, with notable cognitive and motor gains. His quadriplegia remained, however, with fair strength on the right and fair to good overall motor control. At this point a second videofluoroscopic study was attempted, but the results were the same as in the first study. The speech language pathologist then requested a consultation from psychological services. In the psychologist's assessment the patient scored close to 100% with regard to his orientation to all aspects of person, place, time, and situations, and approximately 80% with regard to simple arithmetic and basic problem-solving abilities. Although he had some deficits in higher level cognitive skills, such as deductive reasoning and concept formation, he was able to follow multiple step commands, and his short-term memory was 100% accurate after a 10-rain delay. The patient's dysarthria affected his intelligibility, although he could be understood by a careful listener. The level of fear associated with stimulation of the patient's face and oral cavity was so great that in vivo desensitization (using real-life situations) was not practical in this case. The rationale behind in vitro desensitization (using imaginary scenes) was explained to the patient and the speech language pathologist. The psychologist provided supervision as the speech language pathologist instructed the patient in deep muscle relaxation. His closed head injury had caused increased muscle tone throughout his body, but after 2 days he reported a reasonable level of relaxation. Typically, the hierarchies used in systematic desensitization are constructed by having the patient imagine or experience stimuli and rank numerically the level of fear and anxiety elicited [1 ]. In the present case, a 15-item hierarchy related to the patient's fear of being stimulated around and in the mouth and of swallowing was constructed. The patient reported that he could imagine the scenes in the hierarchy and was able to rate the scenes on a scale of l (slight fear) to l O (very intense fear).
140
G.E. Brown et al.: Systematic Desensitization of Oral Hypersensitivity
Scenes eliciting slight fear and anxiety involved such activities as a nurse bringing a food tray, holding ice cream in the mouth without swallowing, and a tongue blade touching the center of the tongue. The next scenes in the hierarchy gradually elicited progressively higher levels of fear and anxiety and involved activities such as a tongue blade touching the back of the mouth, swallowing pudding, and the last scene, a choking episode after a swallow. The patient was asked, while relaxed, to imagine the least fear- and anxiety-eliciting scene in the hierarchy. After approximately 7 s he was asked to switch to a neutral scene for 7 s and then back to the scene in the hierarchy. This procedure was continued until the patient reported that the scene elicited no fear or anxiety and was repeated for each successive scene in the hierarchy. After 10 days of in vitro desensitization administered by the speech language pathologist, the patient completed the hierarchy and reported that his fear and anxiety had decreased to 0 for the most intense scene in the hierarchy. However, when the speech language pathologist attempted oral stimulation and presentation of food, the patient again exhibited increased muscle tone and fear. Since real-life progress can lag behind progress in imagination [9], and the patient's fear had decreased significantly to items in the first part of the hierarchy, it was decided that an in vivo procedure would now be appropriate. The speech language pathologist constructed a new hierarchy for in vivo desensitization by asking the patient to rank steps in an oral and pharyngeal stimulation regimen on a scale of 1 to 10 with regard to how much fear and anxiety each step generated. The least fear- and anxiety-eliciting steps in the oral and pharyngeal regimen concentrated on touching, with an oral swab, the lips, proceeding inward to the teeth, top of the tongue, dorsum of the tongue, and then gums and inner cheeks. The next items in the hierarchy concentrated on stimulating the hard and soft palate with the dry swab to elicit dry swallows. The speech language pathologist cued the patient in deep muscle relaxation and then proceeded to the first step in the hierarchy. When the patient reported that fear and anxiety associated with the stimulation in the first step had decreased to 0, the therapist proceeded to the next step in the regimen and repeated the procedure. The patient's progress through the new hierarchy was slow and variable. Some steps in the regimen were completed quickly, while others took weeks. No doubt the patient's physical condition contributed to his slow progress. Some days he was in pain, simply could not relax, and therefore no desensitization was attempted. After 37 days of in vivo desensitization the therapist was able to complete each step in the hierarchy without eliciting any fear or anxiety. In addition, the patient was able to swallow a teaspoon of pudding without coughing or apparent aspiration. However, when he was given foods with a different texture or taste he exhibited tension and decreased oral motor control. Additional items involving changes in the amount, texture, and taste of foods were then added to the patient's hierarchy as tolerated. The pureed food was initially placed in his mouth with an oral swab, and then later with a spoon. The amounts of foods presented were gradually increased to a full teaspoon, and the pureed items were gradually varied in texture and taste. Once the patient was tolerating diverse presentations of food and liquids, barium supplements were incrementally added to food items in order to prepare him for a videofluoroscopic study. On the 74th day of in vivo desensitization a videofluoroscopic study was successfully completed. The oral preparatory phase was normal, but the reflex initiation was mildly delayed at the
level of the vallecular spaces. During the pharyngeal phase of swallowing, small amounts of liquid barium and pasty barium entered the valleculae and pyriform sinuses. After the swallow pharyngeal residue was cleared with multiple swallows. No aspiration occurred. On the basis of his videofluoroscopic data the patient was progressed to a regular daily diet consisting of pureed foods, with regular liquids and supplemental feedings at night through his G-tube. He was discharged approximately 1 month later. A 6-month follow-up revealed that the patient was being maintained on the same diet.
Discussion O b v i o u s l y , fear a n d a n x i e t y e l i c i t e d b y t r a u m a t i c e v e n t s d o n o t affect s w a l l o w i n g a n d d o n o t l e a d to the d e v e l o p m e n t o f dysphagia or choking phobias in m o s t p e o p l e . I n m a n y d y s p h a g i c p a t i e n t s f e a r a n d a n x i e t y r e l a t e d to s w a l l o w i n g m a y n o t b e s i g n i f i c a n t f a c t o r s e i t h e r . H o w e v e r , in c e r t a i n p a t i e n t p o p u l a tions the probability that fear and anxiety could be e l i c i t e d by t h e r a p u t i c p r o c e d u r e s o r c h o k i n g i n c i d e n t s s e e m s to i n c r e a s e . F o r e x a m p l e , p a t i e n t s w i t h v a r i o u s t y p es o f c l o s e d h e a d i n j u r y ar e h y p e r s e n s i t i v e t o facial a n d o r a l s t i m u l a t i o n . I n t r e a t i n g t h i s hypersensitivity m o s t head t r a u m a facilities follow s o m e v a r i a t i o n o f F a r b e r [8] a n d a p p l y p r e s s u r e to t h e p e r i o r a l area, p r e s s u r e to t h e c h e e k s a n d t e m p l e s , a n d o n c e t h e p a t i e n t is c a l m e d , m a i n t a i n p r e s s u r e to t h e d o r s u m o f t h e t o n g u e w i t h a r u b b e r s e i z u r e stick in t h e m i d l i n e a p p r o x i m a t e l y o n e - t h i r d b a c k on the tongue. F e a r a n d a n x i e t y c o u l d b e e l i c i t e d in p a t i e n t s w h o find this p r o c e d u r e t r a u m a t i c . A n t i c i p a t o r y anxiety about reoccurrence could then cause further i n c r e a s e s in m u s c l e t o n e , s e n s i t i v i t y , a n d difficulty in s w a l l o w i n g . C h o k i n g i n c i d e n t s t h a t e l i c i t f e a r a n d anxiety could also create anticipatory anxiety and f u r t h e r s w a l l o w i n g difficulties in h y p e r s e n s i t i v e p a tients. S i m i l a r e t i o l o g i e s ar e f o u n d in b e h a v i o r a l m e d icine. In s o m e p a t i e n t s fear a n d a n x i e t y e l i c i t e d by v a r i o u s m e d i c a l a n d d e n t a l p r o c e d u r e s s u c h as i nj e c t i o n s [10], h e m o d i a l y s i s [11], c h e m o t h e r a p y [12], a n d M R I s c a n n i n g [13] g e n e r a t e a n t i c i p a t o r y a n x i ety a b o u t r e o c c u r r e n c e w h i c h c a n t h e n l e a d to t h e development of psychological and physical probl em s. T h e use o f s y s t e m a t i c d e s e n s i t i z a t i o n in this a r e a h as b e c o m e so s u c c e s s f u l in r e d u c i n g a n t i c i p a t o r y a n x i e t y t h a t m e d i c a l a n d d e n t a l p e r s o n n e l ar e o f t e n t r a i n e d to u se d e s e n s i t i z a t i o n . F o r e x a m p l e , G a t c h e l [ 14] t r a i n e d d e n t i s t s to s u c c e s s f u l l y a d m i n i s t e r d e s e n s i t i z a t i o n to g r o u p s o f p a t i e n t s w h o a v o i d e d m a k i n g a p p o i n t m e n t s b e c a u s e o f t h e i r e x t r e m e fear of dental procedures.
G.E. Brown et al.: Systematic Desensitization of Oral Hypersensitivity
Physical problems conditioned to these procedures also occur and can be treated with systematic desensitization. Morrow and Morrell [ 12] used in vivo systematic desensitization to eliminate the association between chronic vomiting and chemotherapy in a cancer patient. Although behaviorists are not universally in agreement concerning theoretical explanations of how systematic desensitization works, after three decades o f research there is no question that in a variety of clinical settings systematic desensitization is an effective procedure [ 1,15]. Therapists responsible for treating dysphagia can easily determine fear and anxiety levels by asking their patients for numerical rankings on stimuli related to swallowing. Where fear and anxiety levels are significant, consultation with psychologists or training in systematic desensitization is appropriate. References 1. Wolpe J: Psychotherapy by Reciprocal Inhibition. Stanford, CA: Stanford University Press, 1958 2. Kaplan PR, Evans IM: A case offunctional dysphagia treated on the model o f fear o f fear. Y Behav Ther Exp PsychiatlT 9:71-72, 1978 3. McNally R J: Behavioral treatment of a choking phobia. Y Behav Ther Exp Psychiatry 17:185-188, 1986
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4. Solyom L, Sookman D: Fear o f choking and its treatment. Can J Psychiatry 25:30-34, 1980 5. Dahlquist LM, Blount RL: Teaching a six-year-old girl to swallow pills. J Behav Ther Exp PsychiatrT 15:171-I 73, 1984 6. Klepac RK, Hauge G, Dowling J: Treatment of an overactive gag reflex: two cases. J Behav Ther Exp Psychiatry 13:141144, 1982 7. Logemann J: Diagnosis and Treatment of Swallowing Disorders. San Diego, CA: College Hill Press, 1983 8. Farber SC: Neurorehabi[itation: A Multisensory Approach. Philadelphia: W. B, Saunders, 1982 9. Bandura A: Principles of Behavior Modification. New York: Holt~ 1969 10. Gatchel R J, Baum A: An introduction to Health Psychology. Reading, MA: Addison-Wesley, 1983 11. Katz RC: Single session recovery from a hemodialysis phobia: a case study. J Behav Ther Exp Psychiatry 5:205-206, 1974 12. Morrow GR, Morrell C: Behavioral treatment for the anticipatory nausea and vomiting induced by cancer chemotherapy. N Engl J Med 307:1476-1480, 1982 13. Klonoff EA~ Janta JW, Kaufman B: The use of systematic desensitization to overcome resistance to magnetic resonance imaging [MRI] scanning. JBehav TherExp Psychiatry 17:189-192, 1986 14. Gatchel RJ: Effectiveness of two procedures for reducing dental fear: group-administered desensitization and group education and discussion, d Am Dent Assoc 101:634-637, 1980 15. Masters JC, Burish TG, Hollon SD, Rimm DC: Behavior Therapy. Techniques and Empirical Findings. New York: Harcourt, Brace, Jovanovich, 1987
Dysphagia ,~ Springer-Ver|agNew York Inc. 1992
Systematic Desensitization of Oral Hypersensitivity in a Patient with a Closed Head Injury Gary E. Brown, Ph.D., ~ Sharon Nordloh, M.A., z and Arlene J. Donowitz, M.D. 2 JU n i v e r s i t y o f T e n n e s s e e a n d 2Cane Creek Center, R e b o u n d , Inc., Martin, Tennessee, U S A
Abstract. A 36-year-old man who had sustained a closed head injury displayed extreme fear of being stimulated in the oral cavity, of being presented with foods, and of swallowing. The patient's fear increased his muscle tone and hypersensitivity in the facial and oral area, thereby preventing assessment of his dysphagia. We describe the use of systematic desensitization to alleviate the patient's fear thus allowing successful completion of a videofluoroscopic barium swallow examination. Key words: Systematic desensitization -- Fear of swallowing -- Deglutition -- Deglutition disorders.
Wolpe [ 1] introduced systematic desensitization as an empirically derived clinical procedure for reducing fear and anxiety associated with specific situations. Since its introduction, variations of the procedure have been developed. These modifications rely on one or more of the three components in the traditional systematic desensitization procedure: (a) teaching the patient progressive muscle relaxation; (b) developing a hierarchy of imaginary scenes or real-life situations that elicit progressively greater levels of fear or anxiety; and (c) pairing relaxation with the least fear- or anxiety-eliciting scene (or reallife situation) in the hierarchy until the anxiety or
Address offprint requests to: Gary E. Brown, Ph.D., University of
Tennessee, Martin, TN 38238-5059, USA
fear disappears--and then proceeding through each item in the hierarchy in a similar fashion. In the behavior therapy literature there are occasional reports on the successful use of systematic desensitization and related behavioral procedures in treating patients who have developed dysphagia following traumatic events. In these cases fear and anxiety elicited by a traumatic event cause some type of swallowing difficulty. The specific symptoms reported vary from case to case, with throat constrictions, a tightness in the throat, a lump in the throat, or a tickling sensation in the throat being the most common. Typically, the patient's anticipatory anxiety about reoccurrence of the swallowing difficulty elicits further swallowing difficulties, and a vicious circle of chronic dysphagia is established involving classical and operant conditioning processes. For example, Kaplan and Evans [2] used desensitization and anxiety-reducing instructions to alleviate dysphagia and a phobia of eating in public in a 29-yrold woman. Her swallowing difficulties originated when she was eating out with her husband, and a gunfight erupted in the restaurant. Although she was not hurt physically, the fear and anxiety associated with the incident caused throat constrictions that led to the development of her dysphagia and her phobia of eating in public. No pharyngeal pathology nor evidence of other etiological factors were found in a physical examination. The dysphagia conditioned by traumatic events is often accompanied by phobias, especially choking phobias. McNally [3] used gradual exposure to a hierarchy of fear-eliciting foods to treat a 30-yr-old man who had developed a fear of choking whenever
G.E. Brown et al.: Systematic Desensitization of Oral Hypersensitivity
certain foods tickled his throat. He denied difficulties in swallowing, but chewed excessively before swallowing. In addition, he chose soft foods such as noodles and ice cream that would not tickle his throat. When he was 16 years old the patient panicked when he choked on a piece of fish. Vicarious conditioning may have sensitized him before this choking incident--although he was not present, his best friend had choked to death on a hot dog several years earlier. Solyom and Sookman [4] used desensitization, tongue exercise, and negative reinforcement to treat three patients with dysphagia and choking phobias. Although fear and anxiety elicited by traumatic events had conditioned dysphagia and choking phobias in all three cases, other possible etiological factors were also reported. All three patients were hypochondriacal, had obsessive personality traits, overprotective mothers, and one or more family members with multiple phobias; one patient had a sister with dysphagia. The three patients also had high anxiety levels when the association between the traumatic events and swallowing difficulties was acquired. There are also reports in the behavior therapy literature on the successful treatment of patients who are unable to swallow pills [5] and patients who have developed overactive gag responses to dental treatment [6]. In the present case, a patient's closed head injury had caused abnormal muscle tone and hypersensitivity in the face and oral area. Fear and anxiety related to being stimulated in the oral cavity, being presented with food or liquids, and swallowing developed in the course of the patient's rehabilitation and caused further increases in muscle tone and hypersensitivity. The patient was unable to enjoy a normal diet and the speech language pathologist could not assess the patient's dysphagia using videofluoroscopic barium swallow procedure [7].
Case Report A 36-yr-old man was admitted to our facility approximately 15 months after sustaining a closed head injury in an automobile accident. On admission to the acute care facility he was resuscitated and intubated. The initial computed tomography (CAT) scan revealed intracerebral hemorrhage involving the right cerebrum and the sylvian fissure warranting emergency right frontal ventriculostomy. A lacunar infarct o f the right caudate nucleus was also noted, but there was no abnormality of the cervical spine. Two weeks later the patient underwent a tracheostomy which was later removed, and 3 months later he had a feeding gastrostomy (G) tube placed. Following these procedures he was trans-
139
ferred to the rehabilitation unit of the hospital for coma stimulation. The patient remained in this unit for 4 months. He was then transferred to a head trauma rehabilitation facility where his hypersensitivity and increased facial muscle tone were treated by daily facial massage and intraoral stimulation [8]. All nutrition was provided via a G-tube. A second CAT scan of his head 14 months following his injury showed encephalomalacia of the left temporal and frontal area secondary to cerebral atrophy, a lacunar infarct of the right caudate nucleus, right thalamic atrophy, and an infarct o f the right periventricular white matter. Ten months later, the patient was transferred to our head trauma rehabilitation facility. On initial evaluation he was awake and alert, with his eyes open and wandering. He was able to track visually to the right only. The patient was spastic quadriplegic with marked increased tone, worse on the left than on the right. In addition, he was found to be extremely sensitive to touch on his face, gums, and tongue. He had increased muscle tone whenever anything was placed in his mouth, an uncontrollable bite reflex, and severe dysphagia; he also required suctioning of saliva. A videofluoroscopic study was attempted, but when the oral preparatory stage was initiated, the patient demonstrated increased muscle tone that interfered with proper positioning and therefore the initiation of normal oral transit. Once a delayed swallow reflex was initiated the patient's vigorous reflexive coughing prevented viewing of the swallowing process and completion of the study. Daily facial massage and intraoral stimulation of the patient's face, gums, and tongue were continued for the next 4 months along with his other therapies. The patient's medical status improved markedly, with notable cognitive and motor gains. His quadriplegia remained, however, with fair strength on the right and fair to good overall motor control. At this point a second videofluoroscopic study was attempted, but the results were the same as in the first study. The speech language pathologist then requested a consultation from psychological services. In the psychologist's assessment the patient scored close to 100% with regard to his orientation to all aspects of person, place, time, and situations, and approximately 80% with regard to simple arithmetic and basic problem-solving abilities. Although he had some deficits in higher level cognitive skills, such as deductive reasoning and concept formation, he was able to follow multiple step commands, and his short-term memory was 100% accurate after a 10-rain delay. The patient's dysarthria affected his intelligibility, although he could be understood by a careful listener. The level of fear associated with stimulation of the patient's face and oral cavity was so great that in vivo desensitization (using real-life situations) was not practical in this case. The rationale behind in vitro desensitization (using imaginary scenes) was explained to the patient and the speech language pathologist. The psychologist provided supervision as the speech language pathologist instructed the patient in deep muscle relaxation. His closed head injury had caused increased muscle tone throughout his body, but after 2 days he reported a reasonable level of relaxation. Typically, the hierarchies used in systematic desensitization are constructed by having the patient imagine or experience stimuli and rank numerically the level of fear and anxiety elicited [1 ]. In the present case, a 15-item hierarchy related to the patient's fear of being stimulated around and in the mouth and of swallowing was constructed. The patient reported that he could imagine the scenes in the hierarchy and was able to rate the scenes on a scale of l (slight fear) to l O (very intense fear).
140
G.E. Brown et al.: Systematic Desensitization of Oral Hypersensitivity
Scenes eliciting slight fear and anxiety involved such activities as a nurse bringing a food tray, holding ice cream in the mouth without swallowing, and a tongue blade touching the center of the tongue. The next scenes in the hierarchy gradually elicited progressively higher levels of fear and anxiety and involved activities such as a tongue blade touching the back of the mouth, swallowing pudding, and the last scene, a choking episode after a swallow. The patient was asked, while relaxed, to imagine the least fear- and anxiety-eliciting scene in the hierarchy. After approximately 7 s he was asked to switch to a neutral scene for 7 s and then back to the scene in the hierarchy. This procedure was continued until the patient reported that the scene elicited no fear or anxiety and was repeated for each successive scene in the hierarchy. After 10 days of in vitro desensitization administered by the speech language pathologist, the patient completed the hierarchy and reported that his fear and anxiety had decreased to 0 for the most intense scene in the hierarchy. However, when the speech language pathologist attempted oral stimulation and presentation of food, the patient again exhibited increased muscle tone and fear. Since real-life progress can lag behind progress in imagination [9], and the patient's fear had decreased significantly to items in the first part of the hierarchy, it was decided that an in vivo procedure would now be appropriate. The speech language pathologist constructed a new hierarchy for in vivo desensitization by asking the patient to rank steps in an oral and pharyngeal stimulation regimen on a scale of 1 to 10 with regard to how much fear and anxiety each step generated. The least fear- and anxiety-eliciting steps in the oral and pharyngeal regimen concentrated on touching, with an oral swab, the lips, proceeding inward to the teeth, top of the tongue, dorsum of the tongue, and then gums and inner cheeks. The next items in the hierarchy concentrated on stimulating the hard and soft palate with the dry swab to elicit dry swallows. The speech language pathologist cued the patient in deep muscle relaxation and then proceeded to the first step in the hierarchy. When the patient reported that fear and anxiety associated with the stimulation in the first step had decreased to 0, the therapist proceeded to the next step in the regimen and repeated the procedure. The patient's progress through the new hierarchy was slow and variable. Some steps in the regimen were completed quickly, while others took weeks. No doubt the patient's physical condition contributed to his slow progress. Some days he was in pain, simply could not relax, and therefore no desensitization was attempted. After 37 days of in vivo desensitization the therapist was able to complete each step in the hierarchy without eliciting any fear or anxiety. In addition, the patient was able to swallow a teaspoon of pudding without coughing or apparent aspiration. However, when he was given foods with a different texture or taste he exhibited tension and decreased oral motor control. Additional items involving changes in the amount, texture, and taste of foods were then added to the patient's hierarchy as tolerated. The pureed food was initially placed in his mouth with an oral swab, and then later with a spoon. The amounts of foods presented were gradually increased to a full teaspoon, and the pureed items were gradually varied in texture and taste. Once the patient was tolerating diverse presentations of food and liquids, barium supplements were incrementally added to food items in order to prepare him for a videofluoroscopic study. On the 74th day of in vivo desensitization a videofluoroscopic study was successfully completed. The oral preparatory phase was normal, but the reflex initiation was mildly delayed at the
level of the vallecular spaces. During the pharyngeal phase of swallowing, small amounts of liquid barium and pasty barium entered the valleculae and pyriform sinuses. After the swallow pharyngeal residue was cleared with multiple swallows. No aspiration occurred. On the basis of his videofluoroscopic data the patient was progressed to a regular daily diet consisting of pureed foods, with regular liquids and supplemental feedings at night through his G-tube. He was discharged approximately 1 month later. A 6-month follow-up revealed that the patient was being maintained on the same diet.
Discussion O b v i o u s l y , fear a n d a n x i e t y e l i c i t e d b y t r a u m a t i c e v e n t s d o n o t affect s w a l l o w i n g a n d d o n o t l e a d to the d e v e l o p m e n t o f dysphagia or choking phobias in m o s t p e o p l e . I n m a n y d y s p h a g i c p a t i e n t s f e a r a n d a n x i e t y r e l a t e d to s w a l l o w i n g m a y n o t b e s i g n i f i c a n t f a c t o r s e i t h e r . H o w e v e r , in c e r t a i n p a t i e n t p o p u l a tions the probability that fear and anxiety could be e l i c i t e d by t h e r a p u t i c p r o c e d u r e s o r c h o k i n g i n c i d e n t s s e e m s to i n c r e a s e . F o r e x a m p l e , p a t i e n t s w i t h v a r i o u s t y p es o f c l o s e d h e a d i n j u r y ar e h y p e r s e n s i t i v e t o facial a n d o r a l s t i m u l a t i o n . I n t r e a t i n g t h i s hypersensitivity m o s t head t r a u m a facilities follow s o m e v a r i a t i o n o f F a r b e r [8] a n d a p p l y p r e s s u r e to t h e p e r i o r a l area, p r e s s u r e to t h e c h e e k s a n d t e m p l e s , a n d o n c e t h e p a t i e n t is c a l m e d , m a i n t a i n p r e s s u r e to t h e d o r s u m o f t h e t o n g u e w i t h a r u b b e r s e i z u r e stick in t h e m i d l i n e a p p r o x i m a t e l y o n e - t h i r d b a c k on the tongue. F e a r a n d a n x i e t y c o u l d b e e l i c i t e d in p a t i e n t s w h o find this p r o c e d u r e t r a u m a t i c . A n t i c i p a t o r y anxiety about reoccurrence could then cause further i n c r e a s e s in m u s c l e t o n e , s e n s i t i v i t y , a n d difficulty in s w a l l o w i n g . C h o k i n g i n c i d e n t s t h a t e l i c i t f e a r a n d anxiety could also create anticipatory anxiety and f u r t h e r s w a l l o w i n g difficulties in h y p e r s e n s i t i v e p a tients. S i m i l a r e t i o l o g i e s ar e f o u n d in b e h a v i o r a l m e d icine. In s o m e p a t i e n t s fear a n d a n x i e t y e l i c i t e d by v a r i o u s m e d i c a l a n d d e n t a l p r o c e d u r e s s u c h as i nj e c t i o n s [10], h e m o d i a l y s i s [11], c h e m o t h e r a p y [12], a n d M R I s c a n n i n g [13] g e n e r a t e a n t i c i p a t o r y a n x i ety a b o u t r e o c c u r r e n c e w h i c h c a n t h e n l e a d to t h e development of psychological and physical probl em s. T h e use o f s y s t e m a t i c d e s e n s i t i z a t i o n in this a r e a h as b e c o m e so s u c c e s s f u l in r e d u c i n g a n t i c i p a t o r y a n x i e t y t h a t m e d i c a l a n d d e n t a l p e r s o n n e l ar e o f t e n t r a i n e d to u se d e s e n s i t i z a t i o n . F o r e x a m p l e , G a t c h e l [ 14] t r a i n e d d e n t i s t s to s u c c e s s f u l l y a d m i n i s t e r d e s e n s i t i z a t i o n to g r o u p s o f p a t i e n t s w h o a v o i d e d m a k i n g a p p o i n t m e n t s b e c a u s e o f t h e i r e x t r e m e fear of dental procedures.
G.E. Brown et al.: Systematic Desensitization of Oral Hypersensitivity
Physical problems conditioned to these procedures also occur and can be treated with systematic desensitization. Morrow and Morrell [ 12] used in vivo systematic desensitization to eliminate the association between chronic vomiting and chemotherapy in a cancer patient. Although behaviorists are not universally in agreement concerning theoretical explanations of how systematic desensitization works, after three decades o f research there is no question that in a variety of clinical settings systematic desensitization is an effective procedure [ 1,15]. Therapists responsible for treating dysphagia can easily determine fear and anxiety levels by asking their patients for numerical rankings on stimuli related to swallowing. Where fear and anxiety levels are significant, consultation with psychologists or training in systematic desensitization is appropriate. References 1. Wolpe J: Psychotherapy by Reciprocal Inhibition. Stanford, CA: Stanford University Press, 1958 2. Kaplan PR, Evans IM: A case offunctional dysphagia treated on the model o f fear o f fear. Y Behav Ther Exp PsychiatlT 9:71-72, 1978 3. McNally R J: Behavioral treatment of a choking phobia. Y Behav Ther Exp Psychiatry 17:185-188, 1986
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4. Solyom L, Sookman D: Fear o f choking and its treatment. Can J Psychiatry 25:30-34, 1980 5. Dahlquist LM, Blount RL: Teaching a six-year-old girl to swallow pills. J Behav Ther Exp PsychiatrT 15:171-I 73, 1984 6. Klepac RK, Hauge G, Dowling J: Treatment of an overactive gag reflex: two cases. J Behav Ther Exp Psychiatry 13:141144, 1982 7. Logemann J: Diagnosis and Treatment of Swallowing Disorders. San Diego, CA: College Hill Press, 1983 8. Farber SC: Neurorehabi[itation: A Multisensory Approach. Philadelphia: W. B, Saunders, 1982 9. Bandura A: Principles of Behavior Modification. New York: Holt~ 1969 10. Gatchel R J, Baum A: An introduction to Health Psychology. Reading, MA: Addison-Wesley, 1983 11. Katz RC: Single session recovery from a hemodialysis phobia: a case study. J Behav Ther Exp Psychiatry 5:205-206, 1974 12. Morrow GR, Morrell C: Behavioral treatment for the anticipatory nausea and vomiting induced by cancer chemotherapy. N Engl J Med 307:1476-1480, 1982 13. Klonoff EA~ Janta JW, Kaufman B: The use of systematic desensitization to overcome resistance to magnetic resonance imaging [MRI] scanning. JBehav TherExp Psychiatry 17:189-192, 1986 14. Gatchel RJ: Effectiveness of two procedures for reducing dental fear: group-administered desensitization and group education and discussion, d Am Dent Assoc 101:634-637, 1980 15. Masters JC, Burish TG, Hollon SD, Rimm DC: Behavior Therapy. Techniques and Empirical Findings. New York: Harcourt, Brace, Jovanovich, 1987
