How do post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and alcohol use disorder (AUD) contribute to the development of gastroesophageal reflux disease (GERD)?

Relationship Between PTSD, Major Depressive Disorder, Alcohol Use Disorder and GERD

There is no direct evidence in the current literature that establishes a clear causal pathway between PTSD with comorbid major depressive disorder and alcohol use disorder causing GERD. However, several connections between these conditions can be identified through existing research.

Psychological Disorders and GERD Connection

• Psychological factors, including stress-related disorders like PTSD, can contribute to functional gastrointestinal symptoms through altered esophageal/visceral pain perception and hypersensitivity 1
• Patients with normal esophageal function tests but persistent symptoms may have functional heartburn, which is associated with psychological factors including altered pain perception 1
• Mental health conditions can augment symptom burden across the entire spectrum of acid exposure, from normal to severe 1

Alcohol Use Disorder and GERD

• Alcohol consumption is a well-established risk factor for GERD symptoms, with studies showing a positive correlation (OR=1.278,95% CI 1.207-1.353) between alcohol intake and GERD development 2
• Moderate to high alcohol consumption can trigger GERD symptoms by affecting esophageal motility and lower esophageal sphincter function 3
• Alcohol is specifically identified as a trigger food/product for GERD symptoms in multiple studies 3

Psychological Stress and GERD

• Poor mental state is positively correlated with GERD (OR=1.278,95% CI 1.207-1.353) 2
• Stress-reactivity and altered perception of visceral signals may contribute to GERD symptoms through dysregulation of the brain-gut axis 1
• Psychological stress can exacerbate gastrointestinal symptoms via alterations in gut motility, epithelial function, or perception of visceral stimuli 1

Comorbidity Patterns

• A study of 9/11 World Trade Center attack survivors found high rates of comorbidity between GERD and PTSD fifteen years after the event, suggesting a potential long-term relationship between these conditions 4
• Nearly half of participants in the WTC Health Registry reported having developed at least one physical or mental health condition (including GERD and PTSD) by 2015-2016, with comorbidity among conditions being common 4
• PTSD and AUD commonly co-occur and are both associated with high global burden of disease 5

Treatment Implications

• For patients with GERD symptoms and psychological comorbidities, adjunctive pharmacotherapy can include neuromodulation with low-dose antidepressants 1
• Behavioral interventions for esophageal disorders with psychological components include cognitive behavioral therapy (CBT), esophageal-directed hypnotherapy, and diaphragmatic breathing 1
• Clinicians should provide pharmacologic neuromodulation and/or referral to a behavioral therapist for hypnotherapy, CBT, diaphragmatic breathing, and relaxation strategies in patients with functional heartburn or reflux disease associated with esophageal hypervigilance and hypersensitivity 1

Lifestyle Factors Connecting These Conditions

• Irregular dietary and lifestyle habits common in those with psychological disorders and substance use disorders can contribute to GERD, including:
  • Midnight snacking (OR=5.08,95% CI 4.03-6.4) 2
  • Eating quickly (OR=4.06,95% CI 3.11-5.29) 2
  • Eating very hot foods (OR=1.81,95% CI 1.37-2.4) 2
  • Eating beyond fullness (OR=2.85,95% CI 2.18-3.73) 2
  • Short interval between dinner and bedtime (OR=7.45,95% CI 3.38-16.4) 2

Diagnostic Considerations

• For patients with persistent symptoms despite PPI therapy, non-GERD etiologies including psychological factors should be investigated 1
• When evaluating GERD symptoms in patients with psychiatric comorbidities, clinicians should consider ambulatory 24-hour pH-impedance monitoring to determine the mechanism of persisting esophageal symptoms 1
• Patients with normal manometry, normal esophageal acid exposure, and a negative symptom association may have functional heartburn related to psychological factors rather than true GERD 1

Management Approach for Patients with Comorbid Conditions

• For patients with both GERD and psychological conditions like PTSD and depression:
  • Address lifestyle modifications including weight loss for overweight patients 1, 6
  • Optimize acid suppression therapy with PPIs as first-line treatment 6
  • Consider adjunctive treatments including alginate antacids for breakthrough symptoms 1
  • Evaluate for psychological therapies targeting both the psychiatric conditions and their impact on GI symptoms 1
  • Consider referral to mental health specialists for integrated treatment of comorbid conditions 1

While direct causation between PTSD, MDD, AUD and GERD is not established in current literature, the evidence suggests multiple potential pathways through which these conditions may interact and exacerbate each other, warranting further research into these relationships.