Introduction

Psychiatric symptoms, such as depression and anxiety, are common prior to bariatric surgery and many patients may continue to experience these symptoms post-surgery [1]. One area that has not been examined in patients who are post-surgery is the development of a food phobia.

Research on food phobia has been associated mostly with a fear of choking [2]. This is described by the avoidance and fear of eating due to the fear of choking on food [2]. Research on food and choking phobias is limited and is restricted to case studies. From these case studies, it appears that choking phobias typically begin suddenly and after a patient has choked or gagged while eating, drinking, or taking pills; although there are also cases where the phobia develops gradually [2]. Some patients have comorbid psychiatric diagnoses, but a food or choking phobia can occur in patients without a psychiatric history [2]. Weight loss is very common in these patients [2]. There are several interventions that have had success in treating food and choking phobias in case studies. These interventions include anxiolytic medications and behavioral interventions such as cognitive behavioral therapy and exposure treatment [2,3,4]. The purpose of this case report is to illustrate the development of a food phobia in a patient who is post-bariatric surgery and to describe the interventions that were used to treat this phobia.

Case report

“Robert” (name changed to protect privacy) was a 47-year-old, black, morbidly obese male who had laparoscopic gastric bypass surgery. At the initial consultation, Robert weighed 430.3 pounds with a body mass index (BMI) of 58.4. Prior to surgery, he completed a routine psychiatric evaluation and denied a history of significant psychiatric symptoms and treatment. He also denied a history of eating disorders (i.e., restriction or purging). From the initial consultation to his surgery date, he lost 18.6 pounds and had a BMI of 55.8.

Robert underwent a routine, laparoscopic gastric bypass surgery. Three months post-surgery he had lost an additional 74.1 pounds (weight = 337.6, BMI = 45.8). At this time, it was noted that he reported choking and vomiting in response to eating. He expressed a fear with regards to these occurring. He was admitted to the hospital, evaluated by gastroenterology, and completed an esophagogastroduodenoscopy (EGD). There were no anatomical or physiological explanations for his difficulty swallowing.

Six months post-surgery, he arrived to a post-surgical follow-up appointment dehydrated and malnourished. He reported that he was unable to eat or drink for several weeks. At this time, he had lost an additional 60 pounds. He was admitted to the hospital for further evaluation and treatment. Findings from an EGD were normal.

A psychiatric consultation was requested for Robert during this inpatient stay. He was not keeping a food journal and reported his food intake by memory. He reported no food intake on most days over the previous several weeks. When he did consume food, he was eating foods not appropriate to his post-surgical diet (i.e., low protein and high carbohydrate foods including fruit, corn, and oatmeal). It appears that he was experiencing frequent dumping syndrome symptoms (i.e., nausea, diarrhea, sweating, vomiting) after consumption of these foods. He appeared to have a lower level of health literacy and limited insight into the proper diet he should be following. Further, he was experiencing anxiety as a result of the dumping syndrome symptoms.

Diagnosis

It appears that Robert developed a specific phobia of food by way of classical conditioning (Fig. 1). He paired eating (a neutral stimulus) with the symptoms of dumping syndrome (unconditioned stimulus), which caused anxiety (unconditioned response). He reported feeling unable to eat, avoided eating, and consistently worried about not being able to swallow. After many repetitions of this, he began to experience anxiety (conditioned response) with eating (conditioned stimulus).

Fig. 1
figure 1

Classical conditioning of a food phobia

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Intervention

Because Robert had limited insight into the types of food he should be consuming post-surgery, he was provided with education on the appropriate diet he should be following by the dietician during his inpatient stay. With the psychologist, he was provided with education regarding his diagnosis of a food phobia and the reasons he was having difficulty swallowing (i.e., anxiety).

To stop the association of anxiety with food, systematic desensitization was chosen as the method of treatment. Systematic desensitization was selected because of the success of this intervention with specific phobias [5]. Systematic desensitization can be used to “counter-condition” and improve avoidance behaviors [6]. This intervention uses graded exposure by allowing the patient to slowly be exposed to the feared behavior or situation while using methods to control the anxiety, such as relaxation techniques. As the patient is able to control the anxiety, the exposure to the feared stimuli is increased further until the situation is no longer anxiety provoking.

During his inpatient stay, Robert identified that thoughts of eating caused distress because of a fear of vomiting. He was taught how to use diaphragmatic breathing. He practiced this and was able to successfully decrease his state anxiety during the session. He was instructed to practice this relaxation strategy prior to eating.

Robert followed up with the psychologist on an outpatient basis about 3 weeks after his discharge. He practiced diaphragmatic breathing and was instructed to visualize himself eating. As his anxiety increased, the visualization was stopped and he would continue the diaphragmatic breathing until his anxiety was at a manageable level. Once his anxiety was manageable during the visualization, he paired the relaxation with the actual consumption of food. After several weeks of repeated pairing of relaxation with consumption of food (approximately 8 months post-surgery), Robert was able to consume food without experiencing anxiety and difficulty swallowing.

At his 1 year post-surgical follow-up appointment, he weighed 225.2 pounds (BMI = 30.5). He was still not keeping a food journal, but denied gastrointestinal complaints at that appointment.

Discussion

Robert appeared to be experiencing a food phobia that developed through classical conditioning. After repeatedly pairing eating with dumping syndrome symptoms, which caused anxiety symptoms, it appeared that eating elicited anxiety and difficulty swallowing. Although there are other cases of avoidance of eating after bariatric surgery [7], this case is unique in that the patient was not motivated to avoid food for the purpose of weight loss or body image. Because of his food phobia, he avoided eating, which led to complications and inpatient admissions to treat dehydration and malnutrition.

Identifying that Robert had a lower level of health literacy was useful because he did not understand what an appropriate post-surgical diet was. This lack of understanding is what perpetuated his dumping syndrome symptoms and led to his fear of eating. Robert needed education at an appropriate level to match his cognitive abilities. Once education was delivered in this manner, he was able to choose foods that aligned with a suitable post-surgical diet. It is essential that patients’ levels of cognitive functioning are understood so that education regarding diet can be communicated effectively. Robert also responded well to systematic desensitization to decrease his anxiety while eating. Once education and systematic desensitization were implemented, Robert had a decrease in anxiety and gastrointestinal symptoms. Thus, it appears that using these interventions for a food phobia can be successful.

In conclusion, it is possible for patients to develop a phobia of food after bariatric surgery, especially if the patient is eating improperly. Interventions that target anxiety, such as systematic desensitization, appear to be useful for improving a phobia of food. Psychoeducation is also an essential part of the treatment and it should be delivered according to the patient’s level of cognitive functioning.