Psychogenic Belching: A Case Report

Conversion symptoms usually appear with emotional conflicts of the patient. Belching’s psychogenic aetiology is not unheard of and can be a manifestation of conversion disorder though rare. Current case is of a middle aged woman presenting with belching unresponsive to medical management. The patient improved after supportive psychotherapy sessions and placebo medication.

A 44-year-old married female of lower socioeconomic strata presented to outpatient department along with her husband with complaints of continuous belching of acute onset, progressive course and continuous in nature for eight months. She also had complains of multiple aches and pain on and off during this period. On detailed enquiry with the family members, her belching would continue throughout the day but would stop when distracted with neutral conversations.

She had consulted a physician and subsequently was referred to a gastroenterologist, and was prescribed two weeks of proton pump inhibitor empirically without any significant improvement in symptoms. Her upper gastrointestinal endoscopy was done and results were unremarkable. Psychiatry consultation was sought after eight months of persistent symptoms. Though she didn’t improve with treatment, her appetite was normal and no weight loss was reported. She had difficulty in onset of sleep due to preoccupation about the stressor. There was no dysphasia, and she would not have any belch during sleep. The sadness of mood and helplessness was reported on enquiry but no suicidal ideation and hopelessness was observed.

The start of belching could be traced to the stressors of death of her mother in law and marriage of her daughter (to both of them patient was attached emotionally) but patient attribute it to the physical illness (pyrexia of unknown origin) she had eight months back. She was having good interpersonal relationship with all her family member but since death of her mother in law there were verbal disputes between her and her sister in laws on trivial issues. She is described to be submissive, unable to make decision for herself or assume responsibility but no clear cut personality disorder could be diagnosed.

On physical examination, she was moderately built with no signs of malnourishment. Heart rate was 90 beats /min and BP-120/70 mm Hg. Systemic examination was unremarkable. She was well kempt and cooperative. Her speech and higher mental function was normal. There was evidence of mild depressive illness, without psychotic features or any other organic mental disorder. She had showed no distress over her belching despite having medical attention for symptoms which were not resolved. She did not show any concern about disruption in her daily activity but would be preoccupied with the other physical complaints like somatic pain and aches.

She was managed with amitriptyline 25 mg for her depressive illness and was investigated so as to find any organic causes of it which yielded no positive correlation. Her thyroid function was within normal limits. About ten sessions of supportive therapy were conducted and injectable multivitamins along with suggestions were also given. Within eight sessions significant improvement was noted in terms of decreased frequency of belches and it almost stopped after next two sessions.

Simultaneously, her psycho education sessions were conducted along with her husband, and she was given insight about the psychological nature of belching and also shown that there was no organic cause for it. She was motivated to take role of her mother in law in her joint family which she was failing to do. Family members were encouraged to be supportive and understanding towards the patient and refrain themselves from criticising the patient and her behaviour.

Expulsion of air from stomach through the mouth is belching which may or may not be associated with odour. The excessive swallowed air distends stomach activating receptors in the gastric wall. This results in reflex relaxation of the lower oesophageal sphincter and escape of intragastric air through the oesophagus [1]. The main causes of belching are Gastroesophageal Reflux Disease (GERD), functional dyspepsia and aerophagia [2]. Belching is modified by attention so that psychogenic cases are not uncommon. [3] Often other symptoms are predominant, and prime attention should be given to treat it first [4]. When excessive belching presents as an isolated symptom then clinical suspicion of psychological belching should also be considered and psychiatric evaluation for early relief should be initiated.

This is a case of conversion disorder with mild depression, where primary symptoms of belching presents as a change in physical functioning. History and mental status examinations suggested an attitude of indifference towards belching. The dependant personality traits of patient may be one of the contributory factors in the genesis of this disorder. Patient could not open up with her husband about family issues which aggravated the symptoms and also the depressive illness. The tangible secondary gain in this case being the excessive attention she gets from her husband.

Supportive psychotherapy helps in achieving desirable outcome in functional dyspepsia as well as reduction of symptoms by providing support and psycho education [5]. Guide therapy is largely as supportive; however, behavioural therapy and psychotherapy may be included [6]. Supportive psychotherapy encouraged the patient to cope up with her environment and at the same time it encouraged family members to be supportive than critical [7]. This approach is helpful in the management of the conversion disorder where symptoms are associated with strong emotions. The cases in urban societies are lower because most people verbalize their problems, however rural and traditional people may be unable to explain their emotional problems with the family members and they manifests as conversion or somatization [8]. The incidence of belching is significantly reduced when patients are distracted or unaware of direct observation which reiterates the importance of psychological factors, and when the psycho education and supportive therapy used would reduce complaints [9]. As there is dearth in literature, only few cases have been reported with serial belches so we would like to highlight this with our current case, which will definitely help for better outcome.

This case reemphasizes the need for the different medical specialities to be well aware of psychiatric illnesses presenting as physical symptoms. This would help in early diagnosis and timely management which would positively address the distress as well as save time and resources.

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