The Mental Health Impact of Retrograde Cricopharyngeus Dysfunction (RCPD) and Its Treatment

ABSTRACT

Objectives

RCPD is a condition characterized by the inability to belch. Our study aims to assess the prevalence of anxiety and depression within this population while evaluating the impact of cricopharyngeal botulinum toxin injection (CPBTI) on associated symptoms.

Methods

RCPD patients selected for treatment with CPBTI were given three validated questionnaires for anxiety (GAD‐7, ASQ) and depression (PHQ‐9) before CPBTI, as well as 6 weeks and 6 months after. The changes were assessed with ANOVA, and minimal clinically important differences (MCID) of the surveys were used to qualify improvement in scores.

Results

Seventy‐seven patients completed the pretreatment questionnaire. Of the 69 patients who ultimately received treatment, 45 completed at least one follow‐up questionnaire and 32 completed all three. Mean age was 30.9% and 61% self‐reported a diagnosed mental health comorbidity (MHC). GAD‐7 identified at least mild anxiety in 73%, 50%, and 46% of patients at each timepoint, respectively. PHQ‐9 identified at least mild depression in 68%, 52%, and 34%, respectively. Mean pretreatment, 6‐week, and 6‐month scores were 8.16, 5.04, and 4.4, respectively, for GAD‐7 (p < 0.001); 7.87, 5.71, and 4.20, respectively, for PHQ‐9 (p = 0.002); and 112.4, 75.6, and 65.20, respectively, for ASQ (p = 0.001). Using MCID values for GAD‐7 and PHQ‐9, 64% showed significant improvement in anxiety and 60% showed significant improvement in depression after treatment.

Conclusion

RCPD patients have a high prevalence of comorbid anxiety and depression. Treatment with CPBTI correlates strongly with a sustained reduction in these symptoms beyond the duration of botulinum toxin.

Level of Evidence

4.

This study assessed the prevalence of anxiety and depression within patients with retrograde cricopharyngeus dysfunction (RCPD) while evaluating the impact of cricopharyngeal botulinum toxin injection (CPBTI) on associated symptoms. Using validated surveys for anxiety and depression given at specific time intervals, RCPD patients were found to have a high prevalence of these mental health disorders, and treatment with CPBTI correlated strongly with a sustained reduction in these symptoms.

1. Introduction

Retrograde cricopharyngeus dysfunction (RCPD) is a condition principally defined by the inability to belch due to failed relaxation of the cricopharyngeus muscle in response to retrograde gastric airflow into the esophagus. While the term was first formally coined in 2019 by Bastian and Smithson [1], there are a few case reports dating back as early as 1987 that describe similar patients [2, 3, 4]. Severity of symptoms in RCPD can be variable, though for many patients this inability to belch can cause significant bloating and associated discomfort in the chest and abdomen. This discomfort is often accompanied by audible gurgling noises arising from the throat that further leads to feelings of embarrassment and social inhibition in public settings [5]. Following the work of Bastian et al., cricopharyngeal botulinum toxin injection (CPBTI) has become the most widely accepted treatment for RCPD, providing not only restoration of the ability to belch, but also significant symptom relief that often lasts indefinitely beyond the expected therapeutic duration of botulinum toxin (BTX) in roughly 70%–80% of patients [1, 5]. While the mechanism behind this enduring treatment effect is not fully understood, there is a thought that the transient period of relaxed cricopharyngeal tone allows patients to retrain the pharyngoesophageal component of the belching reflex.

Interestingly, there has been a recent surge in the presentation of patients with RCPD due to online communities and social media [6, 7]. The first patients described in 2019 by Bastian et al. were largely obtained “from the Internet” without influence from the authors [1]. Social media platforms like Reddit, TikTok, Facebook, and YouTube have provided a forum for anonymous individuals online to share their symptoms and treatment experiences, encouraging others with similar issues to seek care. This has provided a springboard for the prevalence of diagnosed RCPD to drastically increase even in the few years that it has been a recognized disorder, even with our limited data.

Acknowledging the widespread prevalence of mental health disorders like anxiety and depression, particularly in relation to the use and influence of social media [8], physicians who treat RCPD have noted a strong anecdotal correlation between RCPD and comorbid mental health disorders. In the authors' experience, this often includes patient reports of feeling less anxious with overall improved mood following treatment with CPBTI. When considering the overlap between some of the known somatic symptoms of anxiety/depression and the primary symptoms of RCPD, such a correlation seems more plausible.

Very little literature currently exists that explicitly evaluates the relationship between RCPD and mental health, particularly with regards to the impact of long‐term treatment results on objectively measured baseline symptoms. As such, with this study we first sought to define the prevalence of preexisting, comorbid mental health conditions in RCPD patients presenting for treatment, hypothesizing that this prevalence would be significantly greater than that of the general population. Secondarily, we sought to screen patients with validated questionnaires for anxiety and depression before treatment, during the peak of their BTX treatment window, and at least 6 months after treatment to assess for changes in these symptoms following CPBTI. We hypothesized that clinically identifiable levels of anxiety and depression would not only be high prior to treatment, but that these levels would decrease in response to CPBTI while being sustained beyond the expected therapeutic window for BTX.

2. Materials and Methods

This prospective study was approved by the UTHealth Houston Institutional Review Board. Inclusion criteria included patients over 18 years of age with a clinical diagnosis of RCPD who were evaluated in the UTHealth Houston Otorhinolaryngology Clinic. Patients were consented and enrolled after deciding to undergo CPBTI, either via transoral approach in the operating room under general anesthesia or transcervical approach in the office under local anesthesia. Following enrollment, demographic and clinical information was obtained from the electronic medical record, including preexisting formal diagnoses of any mental health conditions.

It is worth noting that while speech language pathologist (SLP) directed behavioral treatment approaches for RCPD have more recently been described (BERP therapy) [9], these strategies had not yet been published at the time our study was being performed. As such, the only treatment offered to this cohort was CPBTI.

The study was designed as a prospective evaluation of the prevalence of mental health comorbidities in patients with RCPD, while also assessing for changes in underlying symptoms of anxiety and depression through a set of validated questionnaires given at select timepoints before and after treatment. The questionnaires utilized included the Generalized Anxiety Disorder‐7 (GAD‐7) and Patient Health Questionnaire (PHQ‐9) for anxiety and depression, respectively, as well as the Anxiety Symptom Questionnaire (ASQ), which is a more novel instrument for anxiety that incorporates the presence of somatic gastrointestinal symptoms [10, 11, 12]. These surveys were chosen for their validity and sensitivity in identifying symptoms of anxiety and depression. GAD‐7 and PHQ‐9 both have an established classification of symptom severity based upon their total score, while ASQ does not. For the GAD‐7, a score of 0–4 represents “minimal,” 5–9 represents “mild,” 10–14 represents “moderate,” and 15+ represents “severe.” The PHQ‐9 is similar, with the adjustment that 15–19 represents “moderately severe” and 20+ represents “severe.” These were used to classify our patient data. Enrolled patients were given all three questionnaires at three time points: (1) prior to CPBTI as a baseline assessment, (2) 6 weeks after CPBTI at the expected midpoint of the BTX therapeutic window, and (3) 6 months after CPBTI to ensure adequate time for complete physiologic washout of the BTX.

Surveys were administered via REDCap (Vanderbilt University, Nashville, United States) and timed for automatic delivery at the aforementioned timepoints. Patients were seen at similar intervals in clinic for posttreatment evaluations to assess treatment response (ability to belch) and associated degree of improvement in RCPD symptoms. Given that no validated instruments were available to objectively assess RCPD symptoms at the time this study was being performed, clinical response was determined based upon patient‐reported subjective improvement in physical symptoms. Responses were categorized as full when symptoms were completely alleviated by unrestricted ability to belch, partial when symptoms were at least somewhat alleviated with some degree of belching ability, and absent when neither was achieved after treatment.

Each of the surveys utilized were numerically scored, and one‐paired ANOVA testing was utilized to compare differences between pretreatment and posttreatment testing for the participants. Additionally, GAD‐7 and PHQ‐9 studies have published values for minimal clinically important differences (MCID) that designate meaningful change in survey score [13]. The MCID was used to identify the quantity of participants that had clinically important impact in their mental health symptoms after CPBTI. Given the potential variability in pretreatment scores for the GAD‐7 and PHQ‐9, we also used a dynamic MCID that changes based upon the starting value, or the “relative MCID” (rMCID) [13]. For those participants with less intense symptoms of anxiety or depression on their initial set of questionnaires where there was little reason to suspect large survey score change, the rMCID was used as a comparison technique to track improvement.

3. Results

Out of 100 patients who met inclusion criteria during the study period from August 2023 to December 2024, 77 ultimately consented for enrollment and completed the baseline pretreatment questionnaires. Of these 77 participants, 52 (68%) were female and 25 (32%) were male. Average age was 30.9 years (range 19–68). Forty‐seven out of 77 participants (61%) self‐reported at least one formally diagnosed mental health comorbidity (MHC). An anxiety disorder was reported in 37 participants, followed by a depressive disorder in 21, attention‐deficit hyperactivity disorder (ADHD) in 15, obsessive–compulsive disorder (OCD) in 2, and post‐traumatic stress disorder (PTSD) in 1 (Table 1). Eight of the 77 participants who completed the baseline questionnaire did not ultimately proceed with CPBTI. Of the 69 treated participants, 32 (46.4%) completed both the 6‐week and 6‐month posttreatment questionnaires, and 45 (65.2%) completed at least one follow‐up questionnaire.

TABLE 1.

Prevalence of self‐reported mental health conditions for participants.

Subgroup	Total N (%)	Average age	MHC N (%)	Anxiety N (%)	Depression N (%)	ADHD N (%)	PTSD N (%)	OCD N (%)
All enrolled participants	77 (100)	30.94	47 (61)	37 (48.1)	21 (27.3)	15 (19.5)	1 (1.3)	2 (2.6)
Completed all three surveys	32 (41.6)	32.25	21 (66)	13 (40.6)	7 (32.9)	10 (31.3)		2 (6.3)
Female	22 (68.8)	31.82	16 (73)	10 (45.5)	6 (27.3)	8 (36.4)		1 (4.5)
Male	10 (31.2)	33.20	5 (50)	3 (30.0)	1 (10.0)	2 (20.0)		1 (10.0)

Abbreviations: ADHD, attention‐deficit hyperactivity disorder; MHC, mental health condition; OCD, obsessive–compulsive disorder; PTSD, post‐traumatic stress disorder.

3.1. RCPD Treatment Response

Of the 69 participants that received CPBTI, 8 were lost to follow‐up and had an unknown degree of benefit in their RCPD symptoms following treatment. An additional 5 patients with known treatment response data at 6 weeks were lost to follow‐up at the 6‐month timepoint. Treatment responses are presented in Table 2, with additional stratification according to the presence of a preexisting MHC. For the six patients that did not have any meaningful response to treatment by their 6 week follow‐up, all were classified as having minimal or mild depression symptoms on pretreatment questionnaires, while two had moderate anxiety symptoms on the pretreatment questionnaire and subsequent mild anxiety on the follow‐up questionnaires.

TABLE 2.

RCPD treatment responses at both timepoints following CPBTI.

	RCPD treatment response after 6 weeks					RCPD treatment response after 6 months
	Full	Partial	None	Unknown	Total	Adequate	Inadequate	Unknown	Total
MHC	31 (86%)	3 (8%)	2 (6%)	5	36	25 (78%)	7 (22%)	9	32
No MHC	20 (80%)	1 (4%)	4 (16%)	3	25	13 (54%)	11 (46%)	4	24
Total	51 (84%)	4 (7%)	6 (10%)	8	61	38 (68%)	18 (32%)	13	56

Note: Results are stratified according to the presence of a formally diagnosed MHC prior to treatment. For long‐term results, a result was considered adequate when a previously developed ability to belch and associated symptom relief had been sustained to a degree that no additional treatment was felt needed.

Abbreviations: MHC, mental health disorder; RCPD, retrograde cricopharyngeus dysfunction.

3.2. Anxiety and Depression Scores According to GAD‐7 and PHQ‐9

Regarding GAD‐7 scores in the pretreatment phase, 21 (27%) out of 77 participants were classified as having minimal anxiety while 26 (34%), 20 (26%), and 10 (13%) were classified as having mild, moderate, and severe anxiety, respectively (Figure 1). Regarding PHQ‐9 scores in the pretreatment phase, 25 (32%) out of 77 participants were classified as having minimal depression while 28 (36%), 14 (18%), 8 (10%), and 2 (3%) were classified as having mild, moderate, moderately severe, and severe anxiety, respectively (Figure 1). Those patients newly identified with moderate to severe anxiety or depression were not directly treated for this during the study time‐period to avoid confounding, but if symptoms persisted at final follow‐up, they were encouraged to seek treatment with their primary care physician or psychiatrist.

FIGURE 1.

Stratification of patients according to severity of mental health symptoms at all three timepoints in the study. Severity was determined using established cutoff values for the GAD‐7 and PHQ‐9. Of note, Moderately‐Severe category only applies to PHQ‐9 scores.

3.3. GAD‐7 Scores Across Study Timepoints

The average scores with associated 95% confidence intervals were calculated for each of the questionnaires at all time points. For GAD‐7, pretreatment overall average was 8.16, 95% CI [6.97, 9.35], with 6‐week and 6‐month averages of 5.05, 95% CI [3.84, 6.25] and 4.40, 95% CI [3.10, 5.70], respectively (Figure 2). ANOVA demonstrated a significant difference for the GAD‐7 data between both pretreatment and 6‐week scores, as well as pretreatment and 6‐month scores (p < 0.001). The average difference in GAD‐7 score from pretreatment to the 6‐week mark was −3.10, 95% CI [−4.26, −1.94] while the average difference to the 6‐month mark was −4.06, 95% CI [−5.6, −2.5]. There was no significant difference between 6‐week and 6‐month GAD‐7 scores.

FIGURE 2.

Mean GAD‐7/PHQ‐9 scores before, during, and after BTX therapeutic window. The p‐values shown represent significance of the referenced values to their pretreatment counterpart only.

3.4. PHQ‐9 Scores Across Study Timepoints

For PHQ‐9, pretreatment overall average was 7.87, 95% CI [6.66, 9.08], with 6‐week and 6‐month averages of 5.71, 95% CI [4.25, 7.17] and 4.20, 95% CI [2.59, 5.81], respectively (Figure 2). ANOVA demonstrated a significant difference for the PHQ‐9 data between both pretreatment and 6‐week scores, as well as pretreatment and 6‐month scores (p = 0.002). The average difference in PHQ‐9 score from pretreatment to the 6‐week mark was −1.98, 95% CI [−3.16, −0.80] while the average difference to the 6‐month mark was −3.86, 95% CI [−5.38, −2.34]. There was no significant difference between 6‐week and 6‐month PHQ‐9 scores.

3.5. ASQ Scores Across Study Timepoints

For the ASQ survey, pretreatment overall average was 112.4, 95% CI [98.3, 126.6], with 6‐week and 6‐month averages 75.6, 95% CI [61.1, 90.2] and 65.2, 95% CI [46.8, 83.6], respectively (Figure 3). ANOVA comparison showed that there was a significant difference for the ASQ data between both pretreatment and 6‐week scores, as well as pretreatment and 6‐month scores (p < 0.001). The average difference in ASQ score from pretreatment to the 6‐week mark was −27.2, 95% CI [−40.4, −14.0] while the average difference to the 6‐month mark was −40.7, 95% CI [−57.8, −23.6]. There was no significant difference between 6‐week and 6‐month ASQ scores.

FIGURE 3.

Mean ASQ scores before, during, and after BTX therapeutic window. The p‐values shown represent significance of the referenced values to their pretreatment counterpart only.

3.6. Assessment of Clinically Significant Change in GAD‐7 and PHQ‐9 Scores

To add to the inherent numerical significance of the differences in these scores, average MCID values of 3.3 for the GAD‐7 and 3.7 for the PHQ‐9 were used to determine the proportion of patients that had a clinically significant change in their pretreatment and posttreatment survey scores. There was clinically important improvement in GAD‐7 scores in 38% of participants at the 6‐week mark and 49% of participants at the 6‐month mark. Similarly, clinically important improvement in PHQ‐9 scores was seen in 24% and 43% at the 6‐week and 6‐month marks, respectively. With regard to the rMCID, once participants with “minimal” scores on the pretreatment GAD‐7 were removed, there was clinically important improvement in GAD‐7 scores in 18 (58%) out of 31 participants at the 6‐week mark and 18 (69%) out of 26 participants at the 6‐month mark. In a similar analysis using rMCID for PHQ‐9, clinically important improvement in PHQ‐9 scores was seen in 16 (62%) and 14 (82%) at the 6‐week and 6‐month marks, respectively.

We see sizeable and significant decreases in scores between pretreatment and posttreatment groups for all three questionnaires that are maintained beyond the expected therapeutic window of BTX. When we remove the participants with “minimal” pretreatment anxiety or depression, we can see the clinically significant implications of these results. For the 26 participants with at least “mild” anxiety that completed both the pretreatment and 6‐month posttreatment GAD‐7, the average score difference was −5.62, 95% CI [−7.25, −3.99]. Given the published MCID of 3.3, we can see that this improvement in patient‐reported anxiety symptoms is both statistically and clinically significant. Within PHQ‐9, there were 22 participants with at least “mild” depression that completed both the pretreatment and 6‐month questionnaires, achieving an average score difference of −5.59, 95% CI [−7.62, −3.56]. With an MCID of 3.7, this difference falls just shy of statistical significance (p = 0.08). We can confidently claim that successful treatment of RCPD with CPBTI can have a significant, positive, and long‐lasting impact on comorbid symptoms of anxiety when present, but more data is needed to make the same claim for comorbid symptoms of depression given this difference between statistical and clinical significance.

4. Discussion

This study highlights the often‐overlooked interplay between physical/somatic symptoms and comorbid mental health disorders. In the case of RCPD and anxiety specifically, it's entirely plausible that many patients developed some degree of their anxiety symptoms in response to the nebulous constellation of gastrointestinal symptoms that had been occurring without a formal diagnosis or explanation. In fact, it was one RCPD patient at our institution whose personal experience prompted us to develop this study. He shared his history of recurring panic attacks during his initial visit. During one such episode, he was somehow able to release a burp without knowing what it was or how he did it, but all his panic and anxiety symptoms faded as soon as he was able to release that pressure. While this is solely one patient's account of a single event, it does highlight some of the deeper connections that we are beginning to understand about the “gut‐brain axis” and how our mental and gastrointestinal health can significantly influence one another [14]. According to available literature from 2022, 18% of United States adults reported symptoms of anxiety and 21% reported symptoms of depression in the prior 2 weeks, using the GAD‐7 and PHQ‐9 questionnaire [15]. Even after treatment with CPBTI, we see a much higher prevalence of symptoms in our RCPD cohort, indicating there may be a deeper underlying connection between the two pathologies.

Our study and results suggest that there are often other physical factors which may be contributing to patients' mental health disorders. In the case of RCPD, these physical issues can often remain undiagnosed for years [16]. Our data further shows that CPBTI for RCPD can simultaneously offer durable treatment for these patients' comorbid mental health conditions, particularly in the case of those with an underlying anxiety disorder. There have been similar trends of data reported elsewhere, where a secondary outcome of GAD‐7 score reduction was seen with successful CPBTI treatment [17]. With the relative lack of awareness of RCPD as a clinical entity [16], it is a near certainty that there are patients unaware they have this condition who have also struggled to manage comorbid health issues. This implies that there may be an alternative treatment to address both of these issues in such patients.

Little is known about the prevalence of RCPD. As mentioned previously, these patients are primarily self‐referred after searching for their symptoms online, and there is little knowledge about the condition among non‐otolaryngology providers. As we learn more about the true prevalence of RCPD, there may be reason to suspect that screening for RCPD during routine mental health evaluations might help identify patients who would be most effectively treated with CPBTI as a first line therapy. It is worth noting that finding a provider that recognizes and appreciates the symptoms of RCPD may in itself help assuage patients' anxiety and mental health symptoms, which may have an additional impact on survey responses. Overall, educating the medical field will be imperative as we continue to investigate this condition.

This study is not without limitations. Among these is the inherent selection bias from patients self‐referring for treatment. Those with anxiety and/or depression related to their health may be more motivated toward independently seeking out treatment. For this reason, the reported incidence of MHC among RCPD patients may actually be lower than reported in this study. Furthermore, specific inquiry into external mental health interventions, such as initiation/modification of psychiatric medications or initiation of psychotherapy was not performed. While this information was never volunteered by patients during their follow‐up visits, it is possible, even if unlikely, that unknown outside intervention may have also impacted our results.

Our follow‐up attrition rate was also a notable limitation. There was a sizeable proportion of participants that did not complete the full set of questionnaires. The participants that did complete their questionnaires may have obtained an overall better mental health outcome that they were more obliged to report. Finally, there is a level of subjectivity to any survey characterizing a condition, especially regarding mental health. While the GAD‐7 and PHQ‐9 are both validated and widely used surveys, it is difficult to capture unbiased answers when asking mental health questions in the frame of RCPD. Participants may positively view their treatment of RCPD, impacting their responses to a questionnaire in the setting of RCPD research. In future studies, blinding participants to the purpose behind administering the mental health questionnaires may produce more impactful results.

5. Conclusion

RCPD patients have a high prevalence of comorbid anxiety and depression. Treatment with CPBTI correlates strongly with a sustained reduction in these symptoms beyond the expected therapeutic duration of BTX. Further, there is evidence that the severity of comorbid anxiety symptoms will decline with successful treatment of RCPD. Future investigations should aim to screen larger groups of patients with and without MHC for RCPD to confirm the validity of these results.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Simko A. P. and Tritter A. G., “The Mental Health Impact of Retrograde Cricopharyngeus Dysfunction (RCPD) and Its Treatment,” The Laryngoscope 136, no. 8 (2026): 3425–3431, 10.1002/lary.70483.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.