Swallowing Disorders in Schizophrenia

Abstract

Disorders of swallowing are poorly characterized but quite common in schizophrenia. They are a source of considerable morbidity and mortality in this population, generally as a result of either acute asphyxia from airway obstruction or more insidious aspiration and pneumonia. The death rate from acute asphyxia may be as high as one hundred times that of the general population. Most swallowing disorders in schizophrenia seem to fall into one of two categories, changes in eating and swallowing due to the illness itself and changes related to psychotropic medications. Behavioral changes related to the illness are poorly understood and often involve eating too quickly or taking inappropriately large boluses of food. Iatrogenic problems are mostly related to drug-induced extrapyramidal side effects, including drug-induced parkinsonism, dystonia, and tardive dyskinesia, but may also include xerostomia, sialorrhea, and changes related to sedation. This paper will provide an overview of common swallowing problems encountered in patients with schizophrenia, their pathophysiology, and management. While there is a scarcity of quality evidence in the literature, a thorough history and examination will generally elucidate the predominant problem or problems, often leading to effective management strategies.

Covert dysphagia and recurrent pneumonia related to antipsychotic treatment

“…13,14 These changes may occur even in the absence of any other signs of parkinsonism and may occur with any firstor second-generation antipsychotic. 7 Other mechanisms, including sedation, 1-7 xerostomia 1-4,6,7 and possibly immune dysfunction, 4,5 have been implicated in the association with pneumonia, but drug-induced pseudoparkinsonism is likely foremost.…”

“…15 Finally, abnormal eating and swallowing habits, predominantly fast eating and taking inappropriately large boluses, have been reported in individuals with schizophrenia for more than 60 years, well before antipsychotics were in common use. 7,16,17 These behaviours often lead to choking, acute asphyxia and aspiration pneumonia.…”

“…Dystonic reactions and tardive dyskinesia can both affect swallowing and lead to aspiration. 7 Drug-induced xerostomia may lead to difficulties with swallowing and ultimately to aspiration. 7 Conversely, clozapineinduced sialorrhea is a risk factor for aspiration pneumonia.…”

“…7 Drug-induced xerostomia may lead to difficulties with swallowing and ultimately to aspiration. 7 Conversely, clozapineinduced sialorrhea is a risk factor for aspiration pneumonia. 15 Finally, abnormal eating and swallowing habits, predominantly fast eating and taking inappropriately large boluses, have been reported in individuals with schizophrenia for more than 60 years, well before antipsychotics were in common use.…”

“…18 No studies have specifically addressed feeding or dietary modifications, but most authors believe that modifications similar to those made for patients with Parkinson disease are reasonable. 7 These include thickening liquids, eating fully upright, tucking the chin before swallowing, minimizing distractions and encouraging smaller bites and sips (using volume control cups, straws and utensils).…”