Importance of the psyche in heartburn and dyspepsia

SUMMARY There is a complex and incomplete relationship between symptoms and altered gastrointestinal physiology in patients with gastro‐oesophageal reflux disease or functional dyspepsia. In patients with reflux disease, symptoms are presumed to relate to the effects of exposure of the oesophageal mucosa to gastric acid and, generally, patients have increased symptoms when damage to the oesophageal mucosa (oesophagitis) occurs. However, it is also recognized that some patients with severe reflux, Barrett's oesophagus or stricture have little history of heartburn: conversely, there is a large group of patients who have acid sensitivity but no oesophagitis or abnormal levels of acid reflux. The relationship between symptoms and delayed gastric emptying is also variable. Clearly, the degree of physiological dysfunction manifested by altered motility (in terms of acid reflux or gastric dysmotility) is not sufficient to account for the symptoms experienced by these patients. One possible explanation for this incomplete association between symptoms and altered gastrointestinal physiology relates to evidence that there are varying degrees of mucosal and neural sensing of the physiological challenges of acid or gastric distension. The evidence for a modulatory role of psychosocial factors, via central nervous system‐enteric pathways, on symptoms of heartburn and dyspepsia is discussed. Preliminary data indicate that psychological treatments may be effective in reducing dyspeptic and psychological symptoms; further work is needed, however, to determine the degree to which these treatments affect gastrointestinal physiology.