Dysphagia
DOI 10.1007/s00455-017-9802-6
REVIEW ARTICLE
Swallowing Disorders in Schizophrenia
Deepika P. Kulkarni1 • Vandan D. Kamath2 • Jonathan T. Stewart1,3
Received: 2 November 2016 / Accepted: 17 April 2017
Ó Springer Science+Business Media New York (outside the USA) 2017
Abstract Disorders of swallowing are poorly character-
ized 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 swal-
lowing 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 extrapyrami-
dal 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 swal-
lowing problems encountered in patients with schizophre-
nia, their pathophysiology, and management. While there is
a scarcity of quality evidence in the literature, a thorough
history and examination will generally elucidate the pre-
dominant problem or problems, often leading to effective
management strategies.
& Jonathan T. Stewart
jonathan.stewart1@va.gov
1
University of South Florida College of Medicine, Tampa,
USA
2
Audiology and Speech Pathology Service (126), James A
Haley VA Hospital, Tampa, USA
3
Psychiatry Service (116A), James A Haley VA Hospital,
13000 Bruce B Downs BLVD, Tampa, FL 33612, USA
Keywords Deglutition
Deglutition disorders

Swallowing
Dysphagia
Airway obstruction
Aspiration

Schizophrenia
Antipsychotics
Introduction
Schizophrenia is a common serious psychiatric illness
associated with recurrent or chronic psychotic symptoms,
affecting about 0.7% of the population [1]. It is a highly
disabling and economically burdensome illness.
Schizophrenia is characterized by positive symptoms
(things that should not normally be present, including
hallucinations, delusions, disorganized thought, and
speech), negative symptoms (a lack of things that should
normally be present, including social withdrawal, avolition,
apathy, flat affect), and cognitive (mostly executive and
attentional deficits) symptoms [1], but both the illness and
its treatment may be associated with a variety of other
medical problems. Disorders of deglutition appear to be
common and potentially serious in schizophrenia but have
not been extensively studied or characterized. For example,
Regan et al. [2] found a prevalence of dysphagia of 23% in
a group of patients with schizophrenia in hospital settings.
Corcoran and Walsh [3] reported a death rate due to
asphyxia (presumably most of this related to choking on
food) of 85/100,000 in psychiatric inpatients in Ireland, a
rate over one hundred times that of the general population.
More recently, Wu et al. [4] reported an odds ratio of
7.92–12.80 (95% CI) for food-related choking death in
schizophrenia as compared to the general population.
These problems are far more prominent in schizophrenia
than in other serious mental illnesses [2, 4–7]. Mortality
and morbidity are generally related to either acute asphyxia
from airway obstruction, or more insidious aspiration
123

pneumonia. This paper will provide an overview of com-
mon swallowing problems in schizophrenia, their patho-
physiology, and management.
Most swallowing disorders in schizophrenia seem to fall
into one of two categories, problems related to the illness
itself and problems related to treatment [8–10]. Problems
related to treatment are better studied and are mostly
related to extrapyramidal side effects (EPS) associated with
antipsychotic medications, although other, non-neurologic
adverse effects such as xerostomia or sialorrhea may also
be significant. Behavioral problems, felt to be inherent to
schizophrenia, consist mostly of a variety of poorly char-
acterized and poorly studied eating behaviors, such as
eating too quickly or taking excessively large boluses of
food. Several authors believe that these behavioral prob-
lems are a greater source of morbidity than the drug-related
problems [11, 12]. Common drug-induced and behavioral
problems are listed in Tables 1 and 2, respectively. It
should be noted that reports of prevalence generally do not
distinguish between these two categories nor between
subcategories of iatrogenic or behavioral problems, and
that the prevalence figures quoted above reflect this.
Drug-Induced Swallowing Disorders
Antipsychotic drugs remain the cornerstone of treatment of
schizophrenia. Most of these drugs block central dopamine
receptors; this blockade is much more extensive with the
older, ‘‘first-generation’’ or ‘‘typical’’ antipsychotics, but is
also seen with most of the newer, ‘‘second-generation’’ or
‘‘atypical’’ agents [13]. Concerns about implications for
swallowing and choking date back to 1957 [14], four years
after chlorpromazine (the first modern antipsychotic) was
released in the United States, and a dose-related association
between antipsychotics and dysphagia is well-established
[15]. Probably the most important implication for swal-
lowing is that blockade of dopamine receptors in the
nigrostriatal tract often leads to drug-induced parkinson-
ism. Drug-induced parkinsonism may present with any or
all the typical signs and symptoms of Parkinson’s disease,
including bulbar symptoms; indeed, Bazemore et al. [8]
Table 1 Common drug-induced swallowing disorders in schizophrenia
Problem
Drug-induced parkinsonism
Dystonic reaction
Tardive dyskinesia
Xerostomia
Sialorrhea
Sedation, inhibited gag
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D. P. Kulkarni et al.: Swallowing in Schizophrenia
noted pathophysiologic similarities to patients with
Parkinson’s disease. As in the case of Parkinson’s disease,
drug-induced parkinsonism may cause poor lingual
movement, slowed and disorganized oral bolus formation,
poor bolus control, and slowed bolus transport during the
oral phase; of note, these changes in oral phase may lead to
premature posterior loss of fluid [16, 17]. Changes in the
pharyngeal phase of swallow are perhaps more predictive
of aspiration or asphyxia, and include delayed, slow, and
incomplete laryngeal elevation, poor pharyngeal peristal-
sis, poor glottic protection, and pooling in the piriform
sinuses with subsequent penetration and aspiration [16, 17].
The esophageal phase is generally believed to be unaf-
fected, although this has not been systematically studied.
There are numerous reports of dysphagia related to drug-
induced parkinsonism, with both first- and second-genera-
tion agents [8–10, 16–24]. Treatment of drug-induced
parkinsonism will usually involve either switching to an
antipsychotic with less extensive dopamine blockade (ei-
ther from a first-generation to a second-generation agent, or
to another agent within class) or treatment with either an
anticholinergic agent (such as benztropine or tri-
hexyphenidyl) or amantadine. To date, there have been a
few reports of improved dysphagia upon switching
antipsychotics [10, 21, 22] or adding an anticholinergic
agent [18] or amantadine [10]. There is also a single report
of successful use of the Mendelsohn maneuver [25] (i.e.,
volitional prolongation of laryngeal elevation), although
the patient was treated with clozapine, which is unlikely to
cause serious drug-induced parkinsonism. There is no lit-
erature regarding feeding or dietary modifications for drug-
induced parkinsonism, but modifications as for Parkinson’s
disease (chin tuck, smaller bites, thickened liquids, etc.) are
probably appropriate if the problem cannot be fully
addressed with changes in the psychotropic drug regimen.
A dystonic reaction is an acute muscle spasm, often
affecting the head and neck, that may occur during treat-
ment with antipsychotics. Dystonic reactions are some-
times seen with first-generation antipsychotics and are
fairly rare with the newer second-generation agents; they
are often seen in younger patients, often during the first few
days of treatment. While dystonic reactions are usually
Common causative agents
Antipsychotics, first generation [ second generation
High-potency first generation antipsychotics
Antipsychotics (chronic use)
Anticholinergic agents (numerous)
Clozapine
Benzodiazepines, sedative agents
D. P. Kulkarni et al.: Swallowing in Schizophrenia
Table 2 Common behavioral swallowing disorders inherent to
schizophrenia
Fast eating (tachyphagia)
Inappropriately large bolus
Inadequate chewing, swallowing unmasticated bolus
Ingesting non-food items
Pocketing food
fairly dramatic and distressing, several authors [23, 26–28]
have reported dysphagia related to dystonias limited to the
jaw, tongue, and pharynx; pharyngeal constrictor palsy,
poor palatal elevation, loss of gag reflex, and severe
oropharyngeal hypomotility have all been reported. Nair
et al. [29] also reported an unusual presentation of a pos-
sible dystonic reaction, uvular swelling that mimicked an
allergic reaction to risperidone but resolved promptly with
benztropine; the authors hypothesized that palatal and
periuvular dystonia inhibited venous drainage. Dystonic
reactions are urgent situations; treatment is generally with
parenteral anticholinergics followed by switching to a drug
with less potent dopamine blockade. It should be men-
tioned that a dystonic reaction may rarely manifest as
laryngospasm; this is a medical emergency that often
necessitates endotracheal intubation [30].
Tardive dyskinesia (TD) is a chronic and often irre-
versible form of EPS that generally occurs after years or
decades of antipsychotic exposure. It presents with
choreoathetoid movements that mostly affect the face, jaw,
and tongue. While the pathophysiology of TD remains
unclear, the predominant view is that it represents a den-
ervation supersensitivity of nigrostriatal dopamine recep-
tors after years of pharmacologic blockade. There have
been reports of dysphagia related to TD, mostly related to
choreiform movements and loss of coordination of the
tongue and muscles of mastication but also to dyskinetic
movements of the pharynx and even the upper esophageal
sphincter [12, 18, 31–34]. Delayed swallow reflex and poor
laryngeal elevation and closure have also been reported
[18, 32, 33]. In severe cases, the diaphragm may be
involved, leading to respiratory incoordination and further
disrupting coordination of swallow [35, 36]. Treatment of
TD is disappointing and far less effective than prevention.
Discontinuation of the antipsychotic if possible, or perhaps
switching to a second-generation agent, is the first line of
treatment and will often result in improvement or resolu-
tion of the TD within three months or so. If TD proves to
be irreversible, modest improvements have been reported
with tetrabenazine. There is little literature about dietary
modification in TD; Sheppard [37] has advocated thick-
ening liquids and encouraging a slower eating pace.
While most iatrogenic swallowing disorders in
schizophrenia are related to antipsychotic-induced EPS,
several other problems may be seen. Many antipsychotics
have strong anticholinergic effects, and xerostomia is a
common complaint. Severe xerostomia may cause diffi-
culty with bolus formation and with oral and pharyngeal
transit [38]. If the medication regimen cannot be changed,
moister foods can be emphasized; some patients will ben-
efit from tart candies (to stimulate saliva production) or
saliva substitutes. Importantly, anticholinergic medications
may also inhibit esophageal peristalsis [39]. Paradoxically,
the most anticholinergic antipsychotic, clozapine, is also a
selective M4 muscarinic receptor agonist and frequently
causes sialorrhea [8, 40]. This can be a source of aspiration
in some patients. Clozapine is typically used in patients
who have failed to respond to any other treatment for
schizophrenia, so it will rarely be feasible to substitute a
different medication. If sialorrhea is severely problematic,
the use of anticholinergic agents (glycopyrrolate, others) or
intraparotid botulinum toxin may be of help [41]. Some
patients with schizophrenia are treated with benzodi-
azepines and other sedating agents, these can inhibit the
gag reflex [42], increasing choking and aspiration risk.
Also, Buchholz [38] reported diffuse pharyngeal paralysis
and aspiration in two patients treated with benzodiazepines,
and Wyllie et al. [43] reported two children with benzo-
diazepine-induced delayed cricopharyngeal relaxation
leading to spillover into the airway; both authors felt that
this was probably mediated at the brainstem level. Finally,
most medications can potentially cause allergic reactions
and angioedema, affecting swallow [44].
Swallowing Disorders Inherent to Schizophrenia
Abnormal eating and swallowing habits may be a greater
factor in aspiration, choking, and asphyxia than drug-in-
duced EPS and other adverse drug effects [11, 12]. These
problems have been reported in schizophrenia for at least
sixty years and well before antipsychotics were in common
use, although this literature is mostly limited to anecdotes
and case reports, many dating back to the 1950s and 1960s
[5, 9, 45, 46]. While there are no systematic studies, these
problems seem more common in more severely ill and
institutionalized patients [2, 9]. Arieti [45] mentions
‘‘tachyphagia’’ as well as a number of other behavioral
changes in his 1955 textbook, ‘‘Interpretation of
Schizophrenia,’’ and indeed, tachyphagia, or fast eating, is
the most frequently mentioned and probably the most fre-
quently encountered behavioral abnormality. Some authors
have attributed this to institutional factors such as limited
time allowed for meals [8, 9], but this seems unlikely.
Perhaps more dangerously, numerous authors have
described patients with schizophrenia taking inappropri-
ately large boluses of food, and this has been noted in many
123

of our patients over the years, often requiring a Heimlich
maneuver and sometimes with fatal outcome [5, 45].
Indeed such large and often unmasticated boluses in the
pharynx or trachea have been reported in autopsies of
patients who have died of acute asphyxia. Other authors
have also reported poor chewing, swallowing of unmasti-
cated food or of non-food items, or pocketing of food in the
mouth [2, 5, 45, 46]. Some authors have mentioned poor
attention or distraction during meals as a contributory
factor [2]. Finally, Keith [47] reported on a cohort of 25
subjects with schizophrenia, observing an immature swal-
lowing pattern with the tongue moving forward and the lips
puckering. The author suggested that these changes might
represent inherent changes in swallowing physiology in
schizophrenia. The author acknowledged, though, that the
noted changes may alternatively have been a subtle man-
ifestation of TD; unfortunately, the extent and duration of
his subjects’ antipsychotic exposure is not reported.
To date, there has been no systematic study of these
behavioral aspects of deglutition in schizophrenia. We have
found these problems to occur more intermittently than
chronically, making risk assessment especially difficult.
Treatment is unclear; to date, there is no data regarding to
what extent, if any, these behavioral problems respond to
treatment of the underlying schizophrenia. A comprehensive
multidisciplinary approach seems most effective; Apple-
baum et al. [11] reported a 75% reduction in choking inci-
dents in their state hospital program. Important elements
included staff education and mealtime supervision, dietary
modification and patient training by the speech pathologist.
Rehabilitative approaches include increasing patient self-
awareness to reduce the speed of eating coupled with verbal
or written cues, and strategies such as training the patient to
put utensils down after each bite and chewing for a pre-
scribed time interval before swallowing. Unfortunately,
carry-over in rehabilitation is often limited in schizophrenia
and many patients will not remember, value, or comply with
these instructions; this may dictate greater reliance on more
passive strategies that do not necessitate as much active
patient participation, such as use of smaller utensils, volume
control cups and straws, or finely cut food [48]. Again, while
there have been no systematic studies to date, the problems
and approaches discussed in this section seem more com-
mon in and more pertinent to more severely ill and institu-
tionalized patients; it is not clear what their role is in less
severely ill and community-dwelling patients.
Conclusions and Future Directions
Disorders of deglutition are surprisingly common in
schizophrenia and represent an important and likely
underappreciated source of morbidity and mortality. Our
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D. P. Kulkarni et al.: Swallowing in Schizophrenia
understanding of these problems is very limited, and there
is a clear need for further research. An important unex-
plored area is the role of medications (including the
switching of antipsychotics) and of focused dysphagia
therapies in mitigating drug-induced swallowing disorders.
Our knowledge of the range of swallowing problems
inherent to schizophrenia is even more limited; there is a
pressing need to better characterize these problems and
their frequency, to identify those patients at highest risk, to
explore their pathophysiology, to determine to what extent
they respond to more aggressive treatment of the under-
lying schizophrenia, and especially to identify best man-
agement and rehabilitation practices. Even without these
advances in our knowledge, though, a thorough focused
history and examination can generally identify the major
problem or problems in any given patient, often yielding
effective management strategies.
Author’s Contribution All of the authors contributed to the con-
ceptualization of this work, literature review, manuscript preparation
and final approval.
Funding There was no sponsorship of this work, and no source of
funding.
Compliance with Ethical Standards
Conflict of interest None of the authors have any actual or potential
financial, personal or other conflict of interest pertinent to this work.
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Deepika P. Kulkarni BS
Vandan D. Kamath MS, CCC-SLP
Jonathan T. Stewart MD, DFAPA, AGSF
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