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The question

I'm afraid of swallowing pills. The size and shape of the pillsmakes no difference; I either crush pills into food or some other suspension, or avoid taking them altogether. The avoidance strategies I have tended to use are getting harder to manage as I get older. What can I do?

The answer

Dysphagia - or difficulties with swallowing - can be related to a range of causes including fear, pain, or some other cognitive, anatomical or physiological problem.

Fear and avoidance of swallowing pills is not an uncommon source of anxiety for people. Although it seems like a very simple and easy task to do, many adults and children will struggle with swallowing pills. The gag reflex is a very powerful - and in true danger situations, a biologically adaptive - reflex. Even having one past experience where you felt as though you were going to gag/choke can reinforce that fear.

Assuming that there is no physiological basis for your difficulties and that the cause is fully psychological, there are some effective strategies to manage your symptoms:

1. Work on relaxation strategies. The fear of swallowing pills (even in the absence of any physiological problem) can lead to the throat tightening up. Learning relaxation strategies can be very helpful, as reducing your overall level of body tension (and also specifically working on relaxing the throat muscles) can help to lessen the automatic response you get when swallowing. Deep breathing and progressive muscle relaxation skills practiced in the minutes before swallowing a pill can be very helpful.

2. Target your fears/thoughts about gagging/choking. You likely have a number of automatic thoughts related to gagging/choking that contribute to your fear, such as: "I can't swallow pills", "I'll never be able to do this", "I hate this", "I will choke". Increase your awareness to inaccurate/catastrophic thoughts and actively replace them with more realistic thoughts (e.g., "I don't like swallowing pills, but my doctor has told me there is no physical reason I can't, and it's never as awful as I think it will be").

3. Visualize success. Picture yourself calmly and easily swallowing the pill. Repeatedly visualizing success can have a very real beneficial impact.

4. Gradually build up your tolerance. Teaching yourself to swallow pills is like building up any other skill: you need to gradually build up your tolerance. Start with very small-sized "simulation pills" and gradually build up the size. Be creative here (e.g., using sprinkles, tic tacs). You want to of course ensure you are only practicing with digestable food that won't cause any health problems (talk to a doctor if you are unsure).

5. Practice, practice, practice! Avoidance of things we fear counter-intuitively increases our fear of those things. So, you need to practice a lot, and not avoid swallowing pills! It can be helpful when you are first building up your tolerance to swallow the pills when someone is around you (e.g., if your worry is about choking). Many people also find eating some food immediately afterward can help with lessening the unpleasant sensation/taste of swallowing the pill.

Drink a lot of water before and after (cool or room-temperature) and take the pill during a time of day when you feel more relaxed and can dedicate some time to implementing your relaxation and realistic thought-replacement strategies.

Note: It would be important to ensure you do speak to your family physician about this to first rule out whether there is any other contribution, as dysphagia is more common in older adults and could be possibly related to some change in muscle or nerve function.

Send psychologist Joti Samra your questions at She will answer select questions, which could appear in The Globe and Mail and/or on The Globe and Mail web site. Your name will not be published if your question is chosen.

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The content provided in The Globe and Mail's Ask a Health Expert centre is for information purposes only and is neither intended to be relied upon nor to be a substitute for professional medical advice, diagnosis or treatment.

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