Aerophagia as the Initial Presenting Symptom of a Depressed Patient

Sir: As reported in the recently published article by Haug et al.,¹ gastrointestinal symptoms are reported in as much as 50% of the general population and are even more common in patients with a diagnosis of an anxiety or depressive disorder. One particular gastrointestinal complaint is aerophagia, which is “a repetitive pattern of swallowing or ingesting air and belching.”² Air swallowing, whether inadvertent or purposeful, is not an uncommon symptom of psychopathology.³ The following case report describes a patient with depression and concomitant aerophagia. Interestingly, the patient initially presented to a health care professional with a chief complaint of chronic and intractable belching and was later diagnosed with depression. This case serves to reinforce the importance of a psychiatric assessment within the primary care setting.

Case report. Ms. A, a 78-year-old married white woman with no prior psychiatric history, initially presented to a psychiatrist following 1 year's duration of chronic belching. There was no reported family history of psychiatric illness. She reported that her own birth occurred after normal gestation and delivery and reached appropriate developmental milestones without any childhood illnesses. She attended 1 year of business college without obtaining a degree and worked as a bank teller until she married her present husband of 54 years. They have 1 son, who lives nearby.

Her medical history is significant for Graves disease, which was treated medically 20 years ago. She also had an episode of temporal arteritis in 1986 that was successfully treated with prednisone at that time. Additionally, she is known to have mitral valve prolapse, osteoporosis, and gastroesophageal reflux disease.

She began experiencing chronic belching in the spring of 2003, which prompted a complete gastrointestinal workup including an upper gastrointestinal and small bowel series, upper and lower endoscopies, gastric emptying study, and abdominal computed tomography. She reported that her belching was continuous except while asleep, and it seemed to be exacerbated by stress. Nausea accompanied her belching, but she denied any vomiting. All studies failed to show a medical reason for her chronic belching, and she was diagnosed with aerophagia secondary to her anxiety and promptly referred to a psychiatrist.

Upon the initial psychiatric assessment, Ms. A also described concomitant psychiatric symptoms that occurred within the same time frame as her chronic belching. She and her husband described her as having a depressed mood for the last year as well as having the inability to laugh or cry. Her sleep had been poor with frequent early morning awakenings. Ms. A also complained of fatigue, poor concentration, and anhedonia. Over the last 2 years, she had noticed a decrease in her appetite and estimated that she had lost approximately 25 pounds. She denied ever having suicidal ideation or a passive death wish. Additionally, her husband noted that she was much more anxious than she had been premorbidly.

After her initial psychiatric visit, the patient was placed on treatment with escitalopram and trazodone, without success. She was then admitted to a psychiatric facility for medication management with inpatient monitoring. During her admission, a video esophagogram found that the patient had a cascading stomach that could have contributed to her chronic belching. Her prior antidepressant was discontinued, and she was subsequently treated with nortriptyline up to a dose of 35 mg and was also placed on an empirical trial of chlorpromazine 10 mg. She was discharged from the hospital and has since had several months free from chronic belching and depressive symptomatology.

To make a diagnosis of aerophagia, 2 criteria must be met: (1) the patient must be observed swallowing air and (2) the patient must experience repetitive belching.² The above conditions must occur at least 12 weeks out of a year and must be troublesome. Patients with aerophagia typically swallow air unconsciously, and it is thought that it is a learned habit. The vast majority of patients with aerophagia actually have an increased frequency of normal swallowing, whereas swallowing large volumes of air is more characteristic of institutionalized patients with aerophagia.⁴ Increased swallow frequency is postulated to be secondary to stress or anxiety. Therefore, patients with aerophagia should be screened for psychiatric illnesses as this can be a common symptom of depression and anxiety.³ If aerophagia is a consequence of a psychiatric illness, then the underlying disease should be treated. Additionally, a study by Calloway et al.⁵ has suggested that biofeedback may be useful. Although dietary modifications are usually suggested (i.e., eating slowly, taking small swallows, and avoiding carbonated drinks), they are rarely successful.² Because stress is thought to contribute to aerophagia, stress reduction techniques could also prove useful.

After a psychiatric diagnostic interview, our patient was found to be suffering from a major depressive episode and had considerable anxiety. She was treated with nortriptyline for her depression and chlorpromazine as an empirical treatment for her aerophagia. Although chlorpromazine is known to be useful in the treatment of intractable hiccups, it is unlikely that the resolution of the patient's symptoms was secondary to chlorpromazine's putative mechanism of action, which is to disrupt the hiccup reflex arc.⁶ Instead, the chlorpromazine most likely aided her via its anxiolytic properties.

In summary, gastrointestinal complaints are commonplace both in the general population and especially in the psychiatric population. Patients who present with aerophagia should be adequately screened for psychiatric illnesses. If aerophagia is diagnosed, there are several behavioral modifications that can be recommended in addition to treating the underlying disorder.