Heartburn, belching, nausea — everybody feels the symptoms of gastroesophageal reflux disease (GERD) from time to time. But do those symptoms come from an actual medical issue? Or are some patients just extraordinarily sensitive to small changes in their digestive tract?
A new study suggests that the answer might depend on the patient’s mental health.
Fernando Herbella, MD, a gastroenterologist at the Federal University of São Paulo in Brazil, and his colleagues examined 222 patients who all suspected they had GERD. Each patient took a 14-item questionnaire to test for anxiety and depression. Some of the patients had these mental health issues and others did not.
Then the researchers observed the pH values in each patient’s esophagus, because an acidic pH value is a common indicator of GERD. They found that nearly half the patients who reported having anxiety and depression had normal pH values in their esophagus — indicating that they most likely did not have GERD.
Are these patients exaggerating the symptoms they feel, or feeling symptoms more acutely? Dr. Herbella believes it’s the latter. “Patients with anxiety and depression or other mental health issues display a ‘hypervigilance’ or ‘hypersensitivity’ to pain sensations,” he says.
In the case of GERD, an extremely common — and usually mild — digestive health problem that affects about 3 million Americans every year, this hypervigilance has curious effects on patient perception. The study found an inverse relationship between anxiety levels and esophagus pH; the more anxious the patient was, the less damaged their esophageal lining. And they found that depression was directly related to esophagus pH — but only in women.
“I really couldn’t even venture a scientific explanation for that,” Herbella says.
The findings, presented at Digestive Disease Week 2018, illustrate just how much psychiatric disorders complicate GERD treatment and diagnosis.
Psychiatric Disorders and Pain Perception
Vic Velanovich, MD, a gastrointestinal surgeon and one of the study’s co-authors, says this is not an isolated phenomenon. It’s part of a broader problem in assessing the severity of disease. “It’s always very difficult to correlate patient-perceived symptoms with actual physiological measures,” he says.
Dr. Velanovich offers a neurological explanation. “It’s called the ‘pain modulation network.’ Pain is converted to electrical signals that travel to the brain. It’s interpreted there by the frontal cortex. So anything happening in the frontal cortex, including mental disorders, makes pain perception worse.”
Velanovich has been exploring the effects of the pain-modulation network for some time. In 2001, he published a study examining whether psychiatric disorders affected patient satisfaction with GERD-correcting surgery. He found that surgery satisfied 93.5 percent of patients without psychiatric disorders, and just 11.1 percent of patients with them.
“It was a classic ‘nocebo’ effect,” Velanovich says. “For both groups of patients the GERD pain was greatly relieved. But only anxious patients found the aftereffects of the surgery intolerable. Which tells me that there’s something else going on.”
This research illustrates how fraught the diagnosis and treatment of GERD can be for gastroenterologists. “The biggest point is that clinicians can’t rely on patient-reported symptoms to diagnose GERD,” Herbella says. “And they certainly shouldn’t skip right ahead to treatment just because a patient is raising complaints. Always look for objective physiological measures before making a diagnosis.”
He also suggests that some of the onus lies with primary care physicians, who he says should be careful to observe any psychiatric issues that occur alongside GERD symptoms.
Velanovich agrees. “My suspicion is that patients with these psychiatric problems are hunting for a physiological cause for some discomfort that they have.”
But he’s careful to emphasize that this is not the patient’s fault. “It’s not a moral failing! People with mental disorders often have little control over their conditions. But it’s important not to give these patients unnecessary treatment that could potentially do them harm. That’s why patients and physicians need to be careful.