Introduction

Defined in the literature as “fear of or avoiding swallowing food, liquids and pills”, swallowing phobia (SP) is also known as “phagophobia and choking phobia” [1, 2]. Although being a rarely encountered clinical entity, SP was considered to be similar to Avoidant/Restrictive Food Intake Disorder (ARFID) by Lopes et al. [2] within the framework of DSM-5 and ICD-11. Lopes et al. [2] stated that SP is characterized by the phobic stimulus of swallowing that results in the avoidance of food or drinks, and ultimately to low weight, social withdrawal, anxiety and depression states. Similar to this study, Okada et al. [1] considered SP as a health problem with the common characteristics of food avoidance emotional disorder and functional dysphagia. Therefore, it may be useful to look at ARFID’s DSM-5 criteria to better understand SP. DSM-5 ARFID defined SP as ‘An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: Significant weight loss (or failure to achieve expected weight gain or faltering growth in children), significant nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, marked interference with psychosocial functioning’ [3]. In addition, it is stated that ARFID does not appear to be involved in another eating disorder (e.g. anorexia nervosa or bulimia nervosa) and it is not related to any other nutritional disorder or cultural practice. It is stated that this disorder cannot be better explained by another medical condition or mental illness, e.g. the person does not have any discomfort related to body image.

In the study conducted by Bailly et al. [4] in 2003, it was suggested that the prevalence of this rarely encountered condition has not yet been evaluated. It is suggested that deglutition-related traumatic experiences may be influential in SP-related cases, which may also be accompanied by panic disorder, obsessive compulsive disorder and separation anxiety diagnoses [5, 6]. However, in addition to eating disorders, another important health problem that should be considered in the differential diagnosis of SP is functional dysphagia (FD). This psychologically based swallowing problem, which can be distinguished from SP by the absence of fear of choking, is that the patient consumes liquids more comfortably than solid food [1]. Patients with a diagnosis of SP have marked acute and chronic phobic symptoms related to the act of eating [1, 2]. It is stated that FD develops on the basis of anxiety, dysthymic features and obsessive phobic reactions [7]. Another psychologically based swallowing problem with a related concept is that of globus histericus (GH). GH is defined as a conversion disorder that is characterized by a feeling of a lump or foreign body in the throat when one attempts to swallow and it is believed to be accompanied by anxiety, depression and personality disorder [8]. However, in a study examining patients with organic dysphagia, clinically relevant symptoms of anxiety were observed in 37% of the patients, clinically relevant symptoms of depression in 32.6% of the patients, and 21.3% of the patients had symptoms of both anxiety and depression on the Hospital Anxiety and Depression Scale [9].

Panic disorder (PD) is an anxiety disorder characterized by recurrent unexpected panic attacks. Between the attacks there is an anxiety of reoccurrence of the panic attacks, and there is also a struggle to prevent possible adverse outcomes and new attacks. In studies investigating the comorbidity of psychiatric diseases, PD was frequently associated with anxiety disorders such as agoraphobia, specific phobia, and social phobia [10–12]. However, one of the symptoms that often accompany panic attacks and PD is choking/swallowing difficulty. In PD-related studies, choking and swallowing difficulty symptoms in PD patients were assessed under the same item [13]. Sheilk et al. [14] found that choking/swallowing difficulty symptoms occurred in 43% of women with PD and 40% of men, while 37% of women with panic attacks and 25% of men had choking/swallowing difficulty during attacks. Sawchuk et al. [15] reported that 40% of PD patient choking/swallowing difficulty in a study investigating lifetime panic attack and PD frequency.

It can be concluded that the clinical features of the choking/swallowing difficulty symptom that are frequently associated with PD have not been examined in detail in the literature. In addition to this, psychologically based swallowing problems (SP, GH, and FD) have not yet been investigated adequately, only with case studies. Therefore, identifying and investigating symptoms of swallowing difficulties associated with PD patients may provide a better understanding of psychologically based swallowing problems. More than this, there are some other benefits of evaluation of the swallowing symptoms in PD patients. First, SP, FD and GH cases are frequently associated with anxiety, phobic features, social anxiety, separation anxiety and obsessive symptoms [6–8]. With regard to this point, it can be said that the comorbidities seen in PD and psychologically based swallowing problems are similar. Second, it can be said that PD diagnosis is common in cases of psychologically based swallowing problems [6]. For these reasons, the primary objective of our study was to describe the signs of swallowing difficulties in PD patients and to investigate the frequency of such symptoms. For this purpose, a scientifically structured measurement tool was needed to measure signs of swallowing difficulty in PD patients. A secondary purpose of this study was to investigate the interaction of the signs of swallowing difficulty in PD patients and possibly related psychopathological features (anxiety, PD, depression, separation anxiety).

Methods

The Bursa Yüksek İhtisas Training and Research Hospital, located in a densely populated and urbanized area in Turkey, provides treatment services for about 650,000 citizens. PD patients who were admitted to the adult psychiatry outpatient clinic of Bursa Training and Research Hospital between March 2014 and February 2016 were recruited to the study. The study consisted of two parts, the pre-phase and the main phase. The pre-phase of the study was carried out between March 2014 and March 2015. The main phase of the study was carried out between March 2015 and February 2016. 22 patients with PD were included who were determined to have swallowing difficulty in the pre-phase of the study and who met the participation criteria for the study.

Materials used to assess swallowing difficulty were created using the descriptions expressed by these 22 patients (this is detailed in the “Procedure” section). 157 patients with PD were invited to participate in the main phase of the study. In this phase, swallowing difficulty items that were obtained in the pre-phase of the study and psychometric tests were used to survey the participants. Participation in the study was voluntary and the study was conducted within the framework of the Helsinki Declaration. For this reason, all participants were given detailed information about the study. In addition, ethics committee approval was obtained from the hospital for the study. In the pre-phase of this study, a non-experimental descriptive design (qualitative research) was used and in the main phase of this study, a correlational design was used.

Participants

DSM-5 was used in the evaluation of psychiatric diagnoses [3]. Inclusion criteria for the pre-phase of the study were: volunteering to participate in the study, having a diagnosis of PD, having graduated from an elementary school (at least) and not exceeding 65 years old. Patients who were evaluated in the pre-phase of the study had a lack of functionality due to swallowing difficulty symptoms. Also, PD patients who had obvious complaints due to difficulty in swallowing were evaluated in the pre-phase of the study. PD patients without swallowing difficulty were excluded from the pre-phase of this study. The patients who were evaluated in this pre-phase of the study were outpatients who had already received psychiatric treatment. In the main phase of the study, 157 patients who volunteered to participate in the study and who met the DSM-5 PD diagnostic criteria were included in the study. In the main phase of the study, acceptance criteria were: volunteering to participate in the study, having PD, having graduated from elementary school (at least), not exceeding 65 years old, and not participating in the pre-phase of the study. The patients who were evaluated in this main phase of the study were outpatients who had already received psychiatric treatment.

According to the diagnostic criteria of DSM-5 in the pre-phase and main phase of the study, patients with schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, neurodevelopmental disorders, obsessive–compulsive and related disorders, and feeding and eating disorders (anorexia nervosa, bulimia nervosa, ARFID) were excluded. In addition, patients with problems in thyroid function, organic dysphagia cases (based on endoscopy results) and those with a history of pharyngeal surgery were also excluded from the pre-phase and main phase of the study.

No patient was excluded from the study due to the exclusion criteria during the pre-phase of the study. For this reason, 22 PD patients who were found to have evident swallowing difficulty were evaluated in the pre-phase of the study. During the main phase of the study, nine uneducated individuals, two patients with bipolar disorder, three patients with anorexia nervosa, two patients with obsessive–compulsive disorder and one patient with psychotic disorder were excluded from the study. Three patients with thyroid function abnormalities and one patient who had pharyngeal surgery (adenoid surgery during the adolescence period) were excluded from the main phase of the study. Six patients whose measurements were incomplete or inaccurate were excluded from the study before the esophageal endoscopy evaluation. In addition, the data of 11 PD patients who completed psychometric measurements correctly but did not give permission for esophageal endoscopic evaluation were not included in the main phase of the study. As a result, in the main phase of the study, 119 PD patients who fulfilled the exclusion criteria of participation in the study and who completed the esophageal endoscopic evaluation and who had no missing or incorrect psychometric measurements were evaluated.

Procedure

22 PD patients who were identified as experiencing dysphagia during the pre-phase of the study were referred to an otorhinolaryngologist. The patients were examined to ascertain whether they had an organic dysphagia (such as cancer, tumor, vocal cord issues, thyroid issues, etc.). Subsequently, 22 PD patients with swallowing difficulty problems were asked to fill out a form about swallowing difficulty. These forms provided information about the patients’ thoughts, feelings and behaviors regarding swallowing difficulty. Later, these texts were examined and 41 expressions that patients used to describe swallowing difficulty were identified. These expressions were evaluated by mental health workers in the field (including one psychiatry professor, two psychiatrists and one psychologist) and 12 different swallowing difficulty items were formed. For example, the phrases “I worry about swallowing bread”, “I worry about swallowing pills” and “I get anxious when I swallow meat” were combined in the same item. These three conditions were therefore expressed as “I get anxious when I swallow something (food, pills, etc.)”. Opinions of two academicians from the Department of Turkish Language and Literature were sought to assess the suitability of the items in terms of language and narrative.

The patients evaluated during the pre-phase of the study were not included in the main phase. The reason for this was that the patients were not identified randomly for the pre-phase of the study. The psychometric evaluation of the 119 PD patients participating in the main phase of the study on a voluntary basis was done prior to their otorhinolaryngologist examination to prevent the anxiety sensitive scales from being affected by the doctor’s examination.

Measures

Panic Agoraphobia Scale Self-rated (PAS-S) determines the severity of PD in patients diagnosed with PD by evaluating patterns such as panic attacks, agoraphobic avoidance, anticipatory anxiety, disability and worries about health [13]. The Cronbach’s alpha of the Turkish version of PAS-S is 0.86 for the Turkish population [16]. The items in the scale are rated between 0 and 4 depending on the severity of the symptoms, and high scores on the scale indicate an increase in the severity of the illness. The cutoff score of the scale was identified as 11 points.

The State-Trait Anxiety Inventory (STAI-1/STAI-2) consists of two scales evaluating the state (STAI-1) and continuing anxiety (STAI-2). The State Anxiety Scale (STAI-1) consists of 20 questions that measure how a person feels at a certain time and under certain conditions [17]. The reliability coefficient of STAI-1 in the Turkish population was found to be between 0.94 and 0.96 [18]. The Trait Anxiety Scale (STAI-2) consists of 20 questions that measure how a person feels, independently of state and conditions that the person is currently in [17]. The cutoff score of the scale was identified as 60 points. The reliability coefficient of STAI-2 in the Turkish population was found to be between 0.83 and 0.87 [18]. STAI-1 and STAI-2 scales are based on self-notification, high scores on both scales indicate an increase in psychopathology.

Beck Depression Inventory (BDI) is a self-report questionnaire that evaluates the intensity of depression [19]. This scale, consisting of 21 items, is evaluated based on a spectrum of 0–63 points, and its Cronbach’s alpha was 0.80 [20]. The cutoff score for the scale was identified as 17 points. High scores on the BDI indicate an increase in depressive symptoms.

Separation Anxiety Symptom Inventory (SASI) is a measuring tool that consists of 15 questions inquiring about childhood separation anxiety symptoms [21]. The Cronbach’s alpha of the Turkish version of SASI is 0.89 for the Turkish population [22]. The cutoff score of the scale was identified as 12 points. High scores on the scale indicate an increase in childhood separation anxiety symptoms. The scale consists of three factors, namely Separation Anxiety, Inability to Stay Away From Family Members and School Phobia.

The swallowing difficulty item list consists of 12 items concerning swallowing difficulty that were created in the pre-phase of the study. They were prepared in the form of Likert items with scores for each item varying between 0 (never) and 4 (always). There is no item that is reverse rated. High scores on the scale indicate an increase in swallowing difficulty. The items related to swallowing difficulty were prepared in Turkish, and native Turkish participants were given these items.

Statistical analysis

The appropriateness of data was evaluated using Bartlett’s test of sphericity, the Kaiser Meyer-Olkin measure of sampling adequacy (KMO) and correlation matrix results. Later, factor analysis was used to evaluate the validity of the items. Internal consistency reliability was measured by Cronbach’s alpha. Independent Sample T test and Kruskal–Wallis Test were employed in the comparison of socio-demographic data. Hierarchical Regression Analysis was used to study the interaction between swallowing difficulty and other psychopathological characteristics. Normal distribution assumptions were met for the Factor Analysis, Cronbach’s alpha analysis, Independent Sample T test, Hierarchical Regression Analysis and Pearson Correlation Analysis. Significance level for all the analyses was determined as p < 0.05. IBM SPSS Statistics 22.0 software was used in analyzing the data.

Results

For the 22 PD patients evaluated during the pre-phase of the study, the age range of the participants varied between 24 and 55 (average ± SD = 37.9 ± 9.2). According to the DSM-5-specific phobia diagnosis criteria, 7 of the 22 patients (31.8%) had some type of SP. In addition, the acute swallowing difficulty symptoms in 15 patients did not meet DSM-5-specific phobia, ARFID, or other food impairment diagnostic criteria. Two of the seven patients had apparent phobia about eating meat and swallowing meat. Four patients showed phobic features of solid foods (bread, meat, etc.). However, one of the patients had marked phobic characteristics associated with ingestion and consumption of fluid and solid food.

Of the 119 participants evaluated in the main phase of the study, 91 of them (76.5%) were women. Their age range varied between 17 and 60 with an average age of 32.3 ± 9.2. 37 of the participants (31.1%) were elementary school graduates (5 years), 23 (19.3%) middle school graduates (8 years), 37 (31.1%) high school graduates (12 years) and 22 (18.5%) university (≥14 years) graduates. In terms of economic status, however, 45 (37.8%) were in the low income group, while 49 (41.2%) were in the middle income group and 25 (21.0%) in the high income group. 56 of the participants (47.1%) were smokers. According to the DSM-5 criteria, 73 of the 119 participants (61.34%) were accompanied by agoraphobia.

Two items were taken off the scale since they failed to provide a normal distribution. Conformity of the data to factor analysis was tested. It was established that the correlation matrices of the items were higher than 0.30. The anti-image correlation coefficients were between 0.85 and 0.92. The common variance values of the items were between 0.43 and 0.62. The factor weight values of the items were between 0.66 and 0.78. It was found that the KMO value of the scale was 0.88 (p < 0.001) and that it accounted for 52.684% of the total variance. As a result of factor analysis, a ten-item measurement tool was created which consisted of a single factor (Table 1).

Table 1 Swallowing Anxiety Scale (SAS) validity and reliability analysis results
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Table 2 The relationship between SAS, PAS-S, SASI, STAI-1, STAI-2 and BDI
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According to the results, Cronbach’s alpha was calculated to be 0.89 as the internal consistency coefficient of the scale. No item was required to be excluded from the scale as a result of Cronbach’s alpha. The correlation coefficients of the scale items with the total scores varied between 0.66 and 0.78. The items were evaluated in terms of their influence on Cronbach’s alpha analysis, and it was concluded that no item was required to be excluded from the scale based on this evaluation (Table 1). Owing to the fact that the scale contained affective and behavioral characteristics that are related to anxious, phobic and somatic characteristics, it was termed the Swallowing Anxiety Scale (SAS). The items of SAS were listed as “Sa1, Sa2, Sa3 … Sa10”.

It was found that SAS items “often” accompany PD patients, ranging between 2.5–10.1%. Additionally, it was found that SAS items “always” accompany PD patients at rates of 5–20.2% (Fig. 1).

Fig. 1
figure 1

Percentage values related to severity of swallowing difficulty symptoms in 119 PD patients

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It was found that there was a highly positive relationship between SAS and PAS-S (r = 0.54, p < 0.001). The correlation between the subscales of SAS and PAS-S varied between 0.25 and 0.53. It was concluded that there was a highly positive relationship between SAS and STAI-2 (r = 0.53, p < 0.001). It was also found that there was an average positive relationship between SAS and STAI-1 (r = 0.45, p < 0.001). The correlation between the subscales of SAS and SASI varied between 0.30 and 0.41. It was also established that there was a highly positive connection (r = 0.50, p < 0.001) between BDI and SAS (Table 2).

It was established that the SAS score averages did not differ based on being a smoker (t = −0.677, p = 0.500), economic status (X 2 = 0.135, p = 0.935) or educational status (X 2 = 5.940, p = 0.115). However, the SAS scale score averages were found to significantly differ (p < 0.001) based on the cutoff scores of STAI-2 (>59), SASI (>11) and BDI (>16). The SAS score average differed significantly (p < 0.001) between PD patients with and without agoraphobia. Only agoraphobia was assessed with DSM-5. Other psychopathological features were measured by psychometric scales (Table 3).

Table 3 Independent groups t test results based on total SAS score
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STAI-2 is a test that is frequently used for measuring general anxiety symptoms. Moreover, for people suffering from psychological based swallowing problems, anxiety is regarded as one of the most important reasons triggering such a condition [6–8]. For this reason, the STAI-2 scale was ranked first in this model. Owing to the fact that the PD symptoms are highly likely to be accompanied by SP diagnosis [6], PAS-S was listed as second. Due to the fact that depression is highly associated with anxiety and that there is a likelihood that it can be observed in people suffering from psychological based swallowing problems [7, 8], we listed BDI scores as third. Due to this listing, we included SASI in the last place of this model. According to hierarchical regression analysis, it was found that the STAI-2 scores accounted for 26% of the SAS scores (p < 0.001), and by articulation of the PAS-S with STAI-2, it accounted for 32% of the SAS scores (p < 0.001). By adding BDI into this model, the accountability ratio rose to 33% and, by adding SASI, it rose to 35%. However, according to the explanation of SAS scale scores in step 4, PAS-S (p < 0.01) and SASI (p < 0.05) seemed to be efficient factors (Table 4).

Table 4 Hierarchical regression analysis results for SAS scores
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Discussion

In this study, symptoms of swallowing difficulty seen in PD patients were defined. We found that swallowing difficulty symptoms accompany PD patients “often” at a rate between 2.5 and 10.1%, and “always” at a rate between 5 and 20.2%. In the literature, the study performed by Sheilk et al. [14] showed that swallowing difficulty accompanies 43% of the females and 40% of the males with PD diagnosis; and the study performed by Sawchuk et al. [15] showed that swallowing difficulty accompanies 40% of the females and 38% of the males with a diagnosis of panic attack. At the same time, Sawchuk et al. [15] reported that 40% of PD patient choking/swallowing difficulty in a study investigating lifetime PD frequency. As a result of these findings, it can be assumed that the association of PD diagnosis with various swallowing difficulty symptoms is high. For this reason, paying attention to swallowing difficulty symptoms in PD patients may contribute to the treatment process of the disease, since swallowing difficulty symptoms in PD patients may cause repetition of panic attacks, nutritional problems or irregular drug usage. Because of this, in PD patients, evaluation of swallowing difficulty symptoms that can negatively affect the functionality of the patient and informing the patient about these psychological symptoms may be useful in terms of treatment.

In this study, a valid and reliable measuring tool of ten items that can measure swallowing difficulty symptoms in PD patients was obtained. Two items of this scale were associated with anxiety symptoms developing in individuals during the swallowing action (Sa1 and Sa9 on Table 1). In addition to this, one item was linked with fear of choking during feeding (Sa7). It is suggested that fear of swallowing may accompany both FD and SP symptoms as psychologically based swallowing problems [1, 2]. In addition, fear of the act of eating is significant in SP diagnosis while fear of the act of swallowing is significant in FD symptoms [1]. At this point, it can be assumed that the anxiety that occurs in PD patients during swallowing has common features with FD and SP diagnoses; however, the thought of choking during feeding is similar to the SP diagnosis. In addition to this, the state of stopping eating due to swallowing problems during eating on the last item of the scale (Sa10) may be associated with both FD and SP symptoms, since repetition of swallowing problems occurring during eating or its exacerbation over time may lead the individual to avoid eating. This is why a swallowing difficulty symptom in PD patients may turn into a complete avoidance of eating over time. In addition to this, it is reported that FD patients consume liquid food more comfortably than SP patients [1]. Therefore, difficulty in consuming solid food on the second item (Sa2) of the scale obtained in this study may be interpreted as a FD symptom.

Globus hystericus is evaluated as a permanent or temporary psychosomatic event characterized by the presence of a lump felt in the throat [8]. Concerning this point, on the scale obtained in this study, the state of obstruction in the throat of the individual at the time of anger (Sa4) and sensing pressure in the throat (Sa5) is similar to GH symptoms. Additionally, on the item of undiscovered physical problem belief of the individual that develops with the swallowing problem (Sa6) and a throat-cleansing behavior (Sa8) may occur in all of the SP, FD and GH diagnoses, since individuals can benefit from the same cognitive, emotional and behavioral components to cope with similar physical and mental symptoms caused by different swallowing problems. Therefore, considering the severity of ten different swallowing difficulty symptoms detected in PD patients may provide a better clinical understanding of these symptoms, since swallowing problems emerging in SP patients are commonly characterized by acute and chronic fear of swallowing and feeding actions [1, 2]. On the other hand, swallowing problems occurring in GH cases are temporary clinical symptoms. In FD patients, significant or severe phobic situations do not accompany feeding action. The clinical symptoms in FD patients are usually distinguished by the severity of the fear of swallowing.

This is the first study to define and analyze in detail swallowing difficulty symptoms in PD patients. In addition, in the literature, psychologically based swallowing problems have been discussed under various diagnoses such as FD, SP and GH. As a result of this, clinical symptoms associated with similarities and differences between these diagnoses have been defined. At the same time, distinguishing the diagnosis of psychologically based swallowing problems and some psychopathologies, including eating disorders, has been discussed. When we analyzed the swallowing difficulty symptoms obtained from PD patients, we found that the symptoms in PD patients had common properties with SP, FD and GH symptoms. We found that the swallowing difficulty items included anxious, phobic and somatic symptoms about swallowing. We, therefore, did not want to define the swallowing difficulty symptoms in PD patients only as phobia or only as a psychosomatic event. Consequently, we suggest the definition “swallowing anxiety” to describe this set of symptoms in PD patients, which we assume to have a wider definition in the psychiatry literature. Because of this, we termed the measuring tool that we have developed to measure swallowing difficulty symptoms in PD patients as the “Swallowing Anxiety Scale”.

Swallowing difficulty symptoms in PD patients can be confused with eating disorders (anorexia nervosa, bulimia nervosa, ARFID). Therefore, it can be necessary to consider especially the ARFID diagnosis, which is newly defined with DSM-5. The SP diagnosis that we evaluated to show common properties with psychological swallowing difficulty symptoms seen in PD patients was suggested to be assessed within the ARFID diagnosis category by some authors [1, 2]. We made the diagnosis of SP for 7 of 22 patients evaluated in the pre-phase of this study according to the DSM-5-specific phobia criteria since the clinical symptoms of SP in these patients did not meet the diagnostic criteria of ARFID (a nutritional deficiency or insufficient provision of energy need). For example, only two of these seven patients had a significant phobia against swallowing food related to meat. At the same time, these patients had a significant drowning fear related to the meat-eating action. Therefore, we suggest in further studies to examine patients representing significant phobic features associated with swallowing but who do not have a significant nutritional problem, since phobic stimulants associated with eating or drowning may not involve the individual’s entire nutritional content and this situation may not cause a significant weight loss in the individual. At the same time, it can be said that patients with these properties (those with a phobia of only swallowing meat and the meat-eating action) are closer to meeting FD and GH diagnosis criteria, since swallowing fear, drowning fear and phobic symptoms against eating seen in patients with a diagnosis of SP have a more acute and chronic view [1, 2].

It has been found that anxiety disorder, PD, phobia, traumatic experiences associated with swallowing, obsessive symptoms and neurotic character traits are associated with psychologically based swallowing problems [5–8]. In addition to this, it was discussed that these psychopathologies may cause psychological swallowing problems. In this study, the association of swallowing difficulty symptoms in PD patients with PD symptoms, anxiety symptoms, separation anxiety and depressive symptoms, supports the opinion that psychological swallowing problems may develop on the basis of anxiety, phobia and somatic symptoms. Besides this, in studies of PB patients, it was discussed that several factors, such as temperament features, negative parent attitudes, and traumatic experiences in childhood, may be linked to different psychosomatic symptoms [23, 24]. Also, the hierarchical regression analysis results in this study point to important effects of these psychosomatic features in explaining swallowing anxiety symptoms. Hierarchical regression analysis shows that PB symptoms and separation anxiety symptoms have significant effects on explaining swallowing difficulty symptoms in PD patients, in addition to general anxiety symptoms. In light of these results, it can be said that swallowing anxiety symptoms in PD patients are linked to neurotic processes, and childhood separation anxiety may cause psychological swallowing problems in advanced ages, since the literature suggests that PD and phobic characteristics may develop based on anxiety sensitivity and that the severity of psychopathologies may increase in line with anxiety sensitivity [25–28]. It is also specified that childhood separation anxiety symptoms may play a significant role in the development of phobic and anxious processes in later years [29]. In addition to this, to better understand swallowing difficulty symptoms, it may be necessary to perform studies of different psychopathologies and different samples.

Swallowing difficulty symptoms that may frequently accompany PD patients have common characteristics with SP, FD and GH symptoms. Moreover, we found that the swallowing difficulty items involved anxious, phobic and somatic symptoms associated with swallowing. For this reason, swallowing difficulty symptoms in PD patients can be described in a more general manner under the definition of “swallowing anxiety”. In addition to this, it may be beneficial in terms of distinguishing diagnoses to take into consideration the swallowing difficulty symptoms when analyzing eating disorder symptoms in PB patients (especially ARFID and anorexia nervosa, bulimia nervosa, etc.). At the same time, taking into consideration that swallowing difficulty symptoms in PD patients are linked with anxiety, separation anxiety and depression symptoms may accelerate the treatment process of the swallowing difficulty symptoms. The limitations of this study, on the other hand, are that the findings can only be generalized for PD patients, that some of the psychopathological characteristics have been measured with pencil and paper tests and that the study included a limited number of persons.