Trauma and gastrointestinal symptoms in patients with gastroesophageal reflux disease: the role of emotional processing and mentalization

Abstract

Aim:

This study seeks to determine, for the first time, whether these mechanisms account for the indirect effects of trauma on gastrointestinal symptom severity within a psychosomatic framework.

Background:

Gastroesophageal reflux disease (GERD) is one of the most common disorders of the digestive system, and various psychological factors may contribute to its development and exacerbation. The present study will examine these factors within a unified analytical model. Specifically, the study aimed to examine a path analysis model of the relationship between trauma and gastrointestinal symptoms in patients with GERD, with a focus on the mediating roles of emotional processing and mentalization.

Methods:

This cross-sectional study included 207 people with gastroesophageal reflux disease referred to Tehran Behbood Clinic, aged 18 to 60 years, selected through convenience sampling. The study was carried out between September and October 2024. The subjects completed the Gastrointestinal Symptom Rating Scale (GSRS), Mentalization Questionnaire (MQ), Childhood Trauma Questionnaire, and Emotional Information Processing Questionnaire (EIPQ). Data were analyzed using path analysis in R (lavaan package) with the Maximum Likelihood Robust (MLR) estimator to account for non-normality. Model fit was evaluated using chi-square, CFI, TLI, RMSEA, and SRMR, and direct, indirect, and total effects were calculated to examine the mediating role of emotional processing and mentalization.

Results:

Trauma had a significant direct effect on gastrointestinal symptoms (β = 0.242, p < 0.001). Emotional processing significantly mediated this relationship (indirect effect β = 0.039, p < 0.05). Mentalization did not show a significant direct or mediating effect on gastrointestinal symptoms (β = 0.074, p = 0.255). Model fit indices indicated excellent fit (CFI = 1.000, TLI = 1.198, RMSEA = 0.000, SRMR = 0.003).

Conclusion:

Based on the findings, it can be concluded that trauma and emotional processing predict gastrointestinal symptoms in patients with gastroesophageal reflux disease and need to be considered in therapeutic interventions.

Introduction

Gastrointestinal disorders impose a considerable burden on healthcare resources in societies, with gastroesophageal reflux disease (GERD) being one of the most common conditions within this category. GERD is characterized by symptoms and complications that are directly related to the backward flow of gastric contents into the esophagus, causing heartburn and the sensation of food getting stuck behind the chest (1). The prevalence of this disease in Western countries is about 10-20%, whereas in Asian countries it is less than 5% (2). The overall prevalence of GERD symptoms in the Iranian population is 5.64% (3). Given the high prevalence and clinical burden of GERD, understanding the psychological factors contributing to its onset and symptom severity is crucial.

Previous studies in psychogastroenterology have consistently shown that psychological factors are strongly and independently associated with the perception of esophageal symptoms in various esophageal disorders, such as GERD, achalasia, and eosinophilic esophagitis. This association remains significant even after controlling for physiological factors, including altered motility, sphincter pressure, and reflux events (4, 5). Specifically, GERD is a common digestive disorder in which multiple psychological factors contribute to its onset and severity.

Trauma is one of the psychological factors that has been identified as influential in this condition, and its association has been confirmed in previous studies (6, 7). It is demonstrated that the onset of functional gastrointestinal disorders has been associated with the experience of severely threatening events (8). According to Kolacz and Porges (2018) (7), exposure to trauma—especially during early life— can lead to chronic disruptions in autonomic nervous system regulation, particularly through alterations in vagal tone. The polyvagal theory posits that such trauma-induced shifts affect neuroception, the body’s unconscious assessment of safety, thereby impairing the regulation of gastrointestinal function even in the absence of structural abnormalities. This dysregulation may manifest as symptoms such as abdominal pain, altered bowel habits, and visceral hypersensitivity. These findings underscore the importance of considering trauma history and autonomic functioning in the assessment and treatment of functional gastrointestinal disorders.

Childhood maltreatment or neglect (developmental trauma), or other forms of psychological trauma, often lead to a reduction in the prefrontal function, resulting in difficulties with mentalization (9). Mentalization is defined as the ability to perceive or interpret both one's and others' actions as intentional, such as feelings, thoughts, fantasies, beliefs, and desires, either implicitly or explicitly (10). This capacity depends on the early interactions between infants and caregivers. When the attachment figure consistently mirrors the infant’s emotional states, emotion regulation evolves through this process (11, 12). Impaired mentalization resulting from childhood trauma can disrupt the ability to regulate emotions effectively (13-15). In patients with functional gastrointestinal disorders, bodily sensations associated with emotional arousal are often misinterpreted as physical abnormalities rather than recognized as manifestations of psychological tension (16). Luyten et al. (2012) (17) propose that impairments in embodied mentalization can contribute to gastrointestinal symptoms in functional somatic disorders. When individuals are unable to recognize emotional arousal as a mental state, they may instead experience it as physical discomfort—particularly in the gut. This misattribution heightens attention to bodily sensations and reinforces maladaptive interpretations of gastrointestinal symptoms as signs of illness rather than emotional distress. In fact, impaired mentalization may prevent patients from identifying the emotional origins of these sensations, leading to an overemphasis on biological explanations for their physical symptoms and contributing to the severity of gastrointestinal complaints.

Figure 1.

Predictive power of the model

Another psychological construct that has been consistently linked to gastrointestinal symptoms in previous studies is emotional processing (18, 19). Studies by Brans et al. suggest that inhibiting or suppressing emotional expression negatively impacts emotional experience (20). While individuals still feel emotions, they suppress their verbal or behavioral expressions, leading to internal tension and emotional repression (21). Over time, this suppression may alter neural systems related to emotions and stress responses, which is the hypothalamic–pituitary–adrenal (HPA) axis. Increasing stress hormones like cortisol, enhancing sympathetic nervous system activity, reducing frontal lobe activity, and increasing amygdala activity (22-24). In this context, due to reduced emotional awareness and limited capacity for affect labeling, individuals tend to misinterpret stress-induced physiological arousal as bodily symptoms, a process referred to as somatic attribution or somatosensory amplification (25). To cope with rising stress, patients often rely on secondary attachment strategies, such as attachment deactivating or hyper-activating behaviors, which may further worsen symptoms by increasing stress and allostatic load, leading to issues like catastrophizing and excessive somatic attributions (17). These physiological changes may disrupt the brain-gut axis, affecting gastrointestinal function and health (19). Central sensitization to esophageal stimuli in GERD patients, mediated by the microbiota-gut-brain axis (MGBA), points to a model where chronic psychological stress augments pain perception. This pathway involves stress-induced activation of the hypothalamic-pituitary-adrenal (HPA) axis and subsequent cortisol release, which promotes intestinal hyperpermeability and compromises epithelial barrier integrity (26, 27).

Despite the established roles of trauma, mentalization, and emotional processing in functional gastrointestinal disorders, their combined and mediating effects have yet to be systematically examined. As the authors are aware, no previous study has simultaneously examined trauma, emotional processing, and mentalization within a unified explanatory model of gastrointestinal symptoms. Moreover, emotional processing and mentalization have not previously been investigated as mediating variables in this context. Therefore, the present study aimed to investigate the impact of trauma on gastrointestinal symptoms by specifically assessing, for the first time, the mediating roles of emotional processing and mentalization among patients with GERD. This study sought to explore how these psychological mechanisms interact to explain the association between trauma and gastrointestinal symptom severity in this clinical population.

Methods

Participants

This cross-sectional study included 207 people with gastroesophageal reflux disease referred to Tehran Behbood Private Medical Clinic, who were recruited using convenience sampling. The inclusion criteria were (a) People with a specialist-confirmed diagnosis of GERD, with no identifiable physiological etiology for their symptoms, (b) aged between 18 and 65 years, living in Tehran, and (c) obtaining verbal informed consent from patients. The exclusion criteria were incomplete responses to the questionnaires. Out of the 220 Patients who received the survey link, 207 provided complete responses and were included in the final analysis. The response rate was 94.9 %.

Procedure

This study was ethically approved by the Student Research Committee of Shahid Beheshti University of Medical Sciences, Iran (Ethical code: IR.SBMU.RETECH.REC.1403.272). Confidentiality and anonymity were assured on the consent form, and participants were informed that their participation was voluntary. Initially, participants were identified by a gastroenterologist and referred to a clinical psychologist. The clinical psychologist then explained the research objectives to the participants and, with their consent, provided them with either a link to the online questionnaire or a paper-and-pencil version of the assessment. Data were collected between September and October 2024 using questionnaires administered in both online and paper-based formats. Of the total questionnaires, 157 were completed in paper-and-pencil format, while the remaining responses were submitted online. For sample size estimation, the Free Statistics Calculators software was used, considering an effect size of 0.3, a power of 0.9, 6 latent variables, 95 observed variables, and an alpha of 0.05, which suggested a sample size of 200 (28-30). However, a total of 220 questionnaires were distributed to account for potential dropouts. Finally, thirteen questionnaires were excluded due to incomplete responses, resulting in a final sample of 207 questionnaires for analysis.

Measures

The data collection process included several questionnaires. Demographic Information Questionnaire:

The items of this questionnaire were specifically designed for this research and collect data on factors such as age, level of education, marital status, occupation, illness, and drug consumption. Patients complete these questionnaires through self-reporting.

Gastrointestinal Symptom Rating Scale (GSRS): The GSRS is a disease-specific tool developed through reviews of gastrointestinal symptoms and clinical experience to assess common symptoms of gastrointestinal disorders. It consists of 15 items, each rated on a seven-point Likert scale ranging from no discomfort to very severe discomfort. Factor analysis has identified five scales within the 15 items: abdominal pain (including abdominal pain, hunger pains, and nausea); reflux syndrome (heartburn and acid regurgitation); diarrhea syndrome (diarrhea, loose stools, and urgent need for defecation); indigestion syndrome (borborygmus, abdominal distension, belching, and increased flatus); and constipation syndrome (constipation, hard stools, and the sensation of incomplete evacuation). Total scores are calculated by averaging the ratings across all items in the questionnaire, with higher scores indicating more severe symptoms. The GSRS demonstrates good internal consistency reliability in patient populations and shows acceptable construct validity and responsiveness (31). The internal consistency reliability for the 5 subscales, according to Cronbach's alpha, is estimated to be 0.62, 0.61, 0.83, 0.80, and 0.70, respectively. The internal consistency for the Iranian sample was 0.86, 0.61, 0.87, 0.86, and 0.75, and its reliability was 0.81, 0.70, 0.70, 0.63, and 0.76 (32).

Mentalization Questionnaire (MQ): This self-report questionnaire, originally developed by Fonagy and colleagues, was later standardized by Dröger et al. It contains 14 items, with each item scored on a 7-point Likert scale from strongly agree to strongly disagree for the certainty component, and reverse scoring for the uncertainty component. Fonagy et al. reported internal consistency of 0.63 for certainty and 0.67 for uncertainty in a non-clinical sample. The test-retest reliability for certainty was 0.74, and 0.85 for uncertainty in the original sample (33). The Cronbach's alpha for the Iranian sample was 0.88 for certainty and 0.66 for uncertainty (34).

The Childhood and Recent Traumatic Events Scale: Developed by Pennebaker and Susman (1988) and standardized by Nobakht and Dale, this questionnaire consists of two sections. TheThe first assesses childhood trauma before age 17 with 6 six traumatic event categories: the death of a close friend or relative, parental separation or divorce, traumatic sexual experiences, exposure to physical violence, major illnesses or injuries, and other significant traumatic experiences. And the second assesses recent 3years trauma with 7 traumatic event categories: the death of a close friend or relative, separation or divorce from spouse, traumatic sexual experiences, exposure to physical violence, major illnesses or injuries, traumatic experiences in work, and other significant traumatic experiences. Each trauma type was assessed with a single item by a yes/no answer. For each event endorsed, participants also rated its perceived intensity on a 7-point scale (1 (not traumatic) to 7 (extremely traumatic)). This questionnaire demonstrates good reliability and validity, along with sensitivity to diverse clinical symptoms. Cronbach’s alpha was not calculated due to the binary nature of the event reporting data(35). In the Iranian sample, the Cronbach's alpha was 0.89 (36).

Emotional Information Processing Questionnaire (EIPQ): Developed by Baker et al., this scale includes five subscales: repression, negative emotional experience, emotion regulation, avoidance, and unprocessed emotional symptoms. The internal consistency and test-retest reliability coefficients for this scale were 0.92 and 0.79, respectively (37). In Iran, the scale's correlation with the emotion regulation scale was 0.54 (38).

Data analysis

Path analysis was conducted to assess the direct, indirect, and total effects of trauma on the outcome variable (Gastrointestinal Symptom Rating Scale [GSRS]), mediated by mentalization and emotional processing. The dataset, initially imported from Excel into R, underwent normality testing via the Shapiro-Wilk test, and checks for linearity and multicollinearity were performed. Due to significant deviations from normality (p < .05), the analysis employed the lavaan package with the Maximum Likelihood Robust (MLR) estimator to ensure reliable results under non-normal conditions. Model fit was evaluated using key indices, including the chi-square test, Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). Direct, indirect, and total effects were calculated to examine the mediating roles of mentalization and emotional processing. All analyses were performed in R, with a significance threshold of p < .05. This analysis represents a path analysis with observed variables, not a full SEM with latent constructs.

Results

Descriptive data

The dataset comprised 207 participants with a mean age of 39.40 years (SD = 10.66). Among the participants, 145 individuals (70.05%) were employed, and 105 (50.72%) were female. In terms of marital status, 78 participants (37.68%) were single, while the remainder were married or in other relationship statuses. Regarding health-related characteristics, 42 participants (20.29%) reported having a diagnosed illness, and 55 (26.57%) were taking medication. Educational attainment varied among the participants: 14 individuals (6.76%) had less than a high school diploma, 57 (27.54%) held a high school diploma, 67 (32.37%) had a bachelor’s degree, 56 (27.05%) had a master’s degree, and 13 (6.28%) had earned a doctorate (Table 1).

Table 1.

Demographic characteristics of participants

Variables		Frequency	Percent
Employment Status
	Employed	145	70.05
	Unemployed	62	29.95
Gender
	Female	105	50.72
	Male	102	49.28
Marital Status
	Single	78	37.68
	Married	129	62.32
Educational Level
	Below Diploma	14	6.76
	Diploma	57	27.54
	Bachelor’s Degree	67	32.37
	Master’s Degree	56	27.05
	Doctorate	13	6.28
Diagnosed Illness		42	20.29
Taking Medication		55	26.57

Note. Frequencies and percentages of participants’ demographic characteristics. Abbreviations: SD = standard deviation.

Table 2 summarizes the frequency and percentage of different types of childhood and adulthood traumas experienced by the participants. Childhood traumas included loss of loved ones, parental divorce, rape, domestic violence, illness, and emotional trauma. Adulthood traumas included loss of loved ones, divorce, rape, domestic violence, illness, significant life changes (e.g., bankruptcy, career decline), and emotional trauma.

Table 2.

Frequency of traumas among participants

Trauma type		Frequency	Percentage
Childhood traumas
	Loss of Loved Ones	72	34.78%
	Divorce of Parents	22	10.63%
	Rape	30	14.49%
	Domestic Violence	54	26.09%
	Illness	42	20.29%
	Emotional Trauma	69	33.33%
Adulthood traumas
	Loss of Loved Ones	86	41.55%
	Divorce	30	14.49%
	Rape	6	2.9%
	Domestic Violence	22	10.63%
	Illness	64	30.92%
	Significant Life Changes (e.g., Bankruptcy, Career Decline)	84	40.58%
	Emotional Trauma (e.g., Humiliation, Abuse)	42	20.29%

Note. Frequencies and percentages of participants reporting childhood and adulthood traumas.

Table 3 presents the descriptive statistics for the main study variables, including mean, standard deviation, skewness, and kurtosis. Trauma scores ranged from X to Y (M = 15.84, SD = 12.15), mentalization (M = 61.02, SD = 11.32), emotional processing (M = 73.37, SD = 12.80), and GSRS (M = 47.02, SD = 16.23). Skewness and kurtosis values indicate acceptable distributions for further path analysis.

Table 3.

Mean and S.D. of variables

Variables	Mean	S. D	Skewness	Kurtosis	Trauma	Mentalization	Emotional processing	GSRS
Trauma	15.84	12.15	1.03	1.62	1
Mentalization	61.02	11.32	0.22	0.16	-0.08	1
Emotional processing	73.37	12.80	-0.27	0.20	0.18**	-0.02	1
GSRS	47.02	16.23	0.12	-0.43	0.27**	0.04	0.25**	1

Note. Descriptive statistics of the study variables, including mean, standard deviation (SD), skewness, and kurtosis

Model fit results

Prior to conducting the path analysis, the assumptions of the model were examined. Normality of each variable was tested using the Shapiro-Wilk test, and significant deviations from normality were addressed using the MLR estimator in the lavaan package. Linearity between predictors and outcomes and multicollinearity among predictors were assessed using scatterplots and variance inflation factors (VIF), respectively, and all values were within acceptable ranges.

The model demonstrated excellent fit indices, indicating a good alignment with the observed data. The chi-square test yielded a value of 0.016 (df = 1, p = 0.901), showing no significant difference between the model and the data. The Comparative Fit Index (CFI = 1.000) and the Tucker-Lewis Index (TLI = 1.198) were well above the recommended threshold of 0.95, indicating an excellent model fit. Additionally, the Root Mean Square Error of Approximation (RMSEA = 0.000, 90% CI [0.000, 0.082], p = 0.923) and the Standardized Root Mean Square Residual (SRMR = 0.003) confirmed the adequacy of the model. These results collectively suggest that the hypothesized model provides an appropriate representation of the relationships among the variables (Table 4). It should be noted that the model has an extremely low degree of freedom (df = 1), which places it in a near-saturated condition. In such models, fit indices (e.g., TLI > 1.0, RMSEA = 0) tend to appear artificially perfect and should not be interpreted as fully reliable indicators of model adequacy. Nevertheless, the path analysis provides meaningful insights into the direct, indirect, and total effects among the observed variables.

Table 4.

Model fit results

Fit index	Chi-square	Df	p-value	CFI	TLI	RMSEA	SRMR
Value	0.016	1	0.901	1.000	1.198	0.000	0.003

Note. Model fit indices for the path analysis examining the effects of trauma on GSRS mediated by mentalization and emotional processing. CFI = Comparative Fit Index; TLI = Tucker-Lewis Index; RMSEA = Root Mean Square Error of Approximation; SRMR = Standardized Root Mean Square Residual.

Direct effects

The analysis revealed several significant direct effects (Table 5). Trauma had a positive and significant direct effect on GSRS (β = 0.242, p < 0.001), indicating a moderate direct influence of the independent variable on the dependent variable. trauma also significantly influenced emotional processing (β = 0.189, p = 0.006), demonstrating a moderate positive relationship. However, the direct effect of trauma on mentalization was not statistically significant (β = -0.086, p = 0.214). Regarding the dependent variable, GSRS, it was significantly affected by emotional processing (β = 0.206, p = 0.002), while the effect of mentalization on GSRS was not significant (β = 0.074, p = 0.255).

Table 5.

Direct effects

Predictor	Outcome	Path Coefficient (𝛽)	Standard Error (SE)	z-value	p-value	Standardized Coefficient (𝛽std)
Trauma	Mentalization	-0.080	0.065	-1.241	0.214	-0.086
Trauma	Emotional processing	0.199	0.072	2.768	0.006	0.189
Trauma	GSRS	0.323	0.089	3.628	0.000	0.242
Mentalization	GSRS	0.107	0.094	1.138	0.255	0.074
Emotional processing	GSRS	0.261	0.084	3.104	0.002	0.206

Note. Direct effects (standardized and unstandardized coefficients) of trauma, mentalization, and emotional processing on GSRS. β = unstandardized path coefficient; β_std = standardized path coefficient; SE = standard error.

Indirect effects

The analysis of indirect effects revealed that trauma significantly influenced GSRS through emotional processing. The indirect effect for this pathway was β=0.039, and it was statistically significant (p<0.05), indicating that emotional processing mediates the relationship between trauma and GSRS in a meaningful way.

However, the indirect effect of trauma on GSRS through mentalization was not statistically significant (β=−0.006, p>0.05). This suggests that mentalization does not serve as an effective mediator between trauma and GSRS.

Total effects

The total effect of trauma on GSRS, which includes both direct and indirect pathways, was β=0.275. This total effect was statistically significant, indicating that trauma significantly impacts GSRS both directly and indirectly through the mediation of emotional processing. The direct effect of trauma on GSRS was β=0.242, and the indirect effect through emotional processing contributed an additional β=0.039. The negative indirect effect through mentalization was negligible (β=−0.006) and not statistically significant.

Predictive power

The overall predictive power of the model was evaluated by examining the explained variance (R2) for the key outcome variable, GSRS. The model explained a modest proportion of the variance in GSRS (R²=0.121), suggesting that the predictors (trauma, emotional processing, and mentalization) accounted for 12.1% of the variability in GSRS.

For the mediating variable emotional processing, the explained variance was relatively low (R2=0.036), indicating that trauma had a limited predictive influence on emotional processing. Similarly, the variance explained for mentalization was very small (R²=0.007), suggesting that trauma had minimal predictive power for mentalization.

Discussion

This study investigated the link between trauma and gastrointestinal symptoms, with emotional processing and mentalization as mediators, in patients diagnosed with gastroesophageal reflux disease (GERD). The findings indicate both direct and indirect effects of trauma on the severity of gastrointestinal symptoms, highlighting the role of emotional processing as a key mediator. However, the interpretation of these results must consider the sample's demographic characteristics. The mean age of respondents was 39.40 years (SD = 10.66), and 50.72% were female. Since age and gender can influence both emotional processing and the experience of gastrointestinal symptoms, the observed relationships may partly reflect these demographic trends. The model explained a moderate percentage of variance in GSRS scores (R² = 0.121), indicating that the predictors accounted for only a limited portion of the variability. Thus, unobserved factors—such as lifestyle, medication use, or comorbid medical conditions—likely also contribute to symptom severity.

Analysis of the model confirmed the hypothesis of a significant direct effect of trauma on gastrointestinal symptoms. Consistent with the present results, studies by Nass et al. (2024) and Gradus et al. (2017) have also reported a significant link between gastrointestinal symptoms and trauma (39, 40). However, as this was a cross-sectional study, these relationships must be considered correlational rather than causal. In contrast, Bradley et al. reported discrepant findings, suggesting that stress may cause low-grade esophageal irritation that can be mistaken for GERD symptoms (41). Trauma, particularly post-traumatic stress and distress, is known to aggravate gastrointestinal symptoms through physiological mechanisms. Specifically, it can increase esophageal sensitivity to acid exposure by enhancing visceral hypersensitivity. While this rationale aligns with established models of stress and pain, the present study did not directly examine nervous system mechanisms. Therefore, these mechanisms should be viewed as theoretical postulations supported by the existing literature, rather than as findings established by this study. The phenomenon is thought to involve both central and peripheral sensitization, whereby stress affects pain inputs via the amygdala and anterior cingulate gyrus, leading to a lowered pain threshold and heightened perception of gastrointestinal symptoms (42). Additionally, trauma-induced stress impairs lower esophageal sphincter function, thereby increasing the incidence of gastroesophageal reflux. (43). Although many studies demonstrate an association between trauma and gastrointestinal symptoms, the nature of this association is often unclear. The current results suggest a pattern where emotional processing mediates this relationship, though the study design precludes causal inferences.

The results demonstrated a statistically significant indirect effect for emotional processing, supporting the proposed mediation model. However, this indicates an association rather than definitive evidence of causation. Research conducted by Aleya et al. (2024) and Bloomfield et al. (2021) corroborated the current hypothesis by identifying a significant correlation between trauma and emotional processing (44, 45). Furthermore, studies by Caes et al. (2017), Mazaheri et al. (2015), and Urnes et al. (2009) also supported the hypothesis of the current study by revealing a connection between emotional processing and gastrointestinal symptoms (46-48). Trauma has a profound impact on information processing and can result in attentional biases. Consequently, individuals with a history of trauma may experience difficulties in processing emotions due to a disruption in the automatic regulation of emotional conflicts (49). Through hyper-reactivity of the amygdala and other regions associated with emotions, trauma—particularly during early developmental stages—can lead to reductions in the volume of certain brain areas while causing hyperactivity in others (50). This neural imbalance may contribute to impaired emotional processing (51). Traumatic experiences can induce adaptations in emotional processing, potentially increasing gastrointestinal symptoms via the gut-brain axis, which links the autonomic and central nervous systems (52). Adaptations in the neural circuitry of the HPA axis can heighten hypersensitivity and subsequently amplify pain perception (53), a process that may be influenced by anxiety, depression, and emotional dysregulation (54, 55). High levels of emotional distress are correlated with reduced tolerance for gastrointestinal symptoms and higher reported pain intensity. Conversely, skill in emotional processing may reduce symptom severity and promote greater symptom acceptance (56).

A further finding was that mentalization did not mediate the association between trauma and gastrointestinal symptoms in GERD patients. This null result requires careful interpretation. One possibility is that the strong direct link between trauma and gastrointestinal symptoms overwhelmed any potential indirect effects through mentalization. Another explanation may be methodological, relating to the specific measure of mentalization used or a lack of variance in scores. Additionally, mentalization may be more relevant to interpersonal or attachment disorders than to somatic symptoms. In line with this finding, Benfante et al. (2023) did not validate a connection between mentalization and gastrointestinal symptoms (57). Therefore, the absence of mentalization playing a mediating function needs to be interpreted with caution and studied further in standardized instruments and clinically heterogeneous populations of patients. It is also important to note that the Mentalization Questionnaire (MZQ) used in this study primarily assesses cognitive and interpersonal aspects of mentalization—that is, the understanding of one's own and others' mental states. In contrast, somatic or self-focused aspects of mentalization (e.g., the experience and interpretation of one's own bodily feelings) are not directly evaluated (58). Given that our sample comprised patients with gastrointestinal symptoms, the MZQ's lack of focus on these somatic aspects may partly explain the absence of a significant mediating role for mentalization in our model (58).

The findings also have clinical implications. Identifying trauma and patterns of emotion processing in GERD patients could inform psychological interventions. Treatments such as Emotion-Focused Therapy (EFT) and mindfulness-based stress management have been shown in previous studies to reduce symptom severity and improve emotional regulation in GERD (59, 60).

This study has several limitations. First, the cross-sectional design precludes causal inferences between the variables. Second, the use of self-report questionnaires may introduce response bias. Third, the sample was recruited from a single clinic in Tehran, which may limit the generalizability of the findings. Fourth, the use of both online and paper-based methods may have introduced measurement bias. Fifth, although the sample size was adequate for structural equation modeling (SEM), it may have been underpowered to detect smaller effects.

Subsequent studies must adopt longitudinal or experimental designs in order to delineate causal connections. Besides emotional processing, subsequent models should also include such factors as coping style, social support, and perception of pain, as they may explain residual unaccounted variance in GSRS. Intervention studies based on emotion regulation training as a prototype may also reduce gastrointestinal symptoms and obtain improved patient results. Finally, we suggest that other researchers use the Mentalization Questionnaire, which focuses on assessing self and body feelings.

Conclusion

We found that the association between trauma and gastrointestinal symptomatology in GERD patients was statistically mediated by emotional processing but not by mentalization. Given the correlational design and the moderate amount of variance explained, these results should be considered tentative and hypothesis-generating rather than definitive. Our study highlights the potential of emotional processing as a therapeutic target for GERD patients with a history of trauma, and we recommend further longitudinal studies to validate these relationships causally.

Conflict of interests

There is no conflict of interest for authors of this article.