Anxiety and GERD: Reversing the Therapeutic Order to Heal the Root Cause
The Therapeutic Order is really a hierarchy of naturopathic modalities and therapeutic interventions based on centuries of observation from the healing process.1 In many cases, gastroesophageal reflux disease is a condition that could be eloquently treated using the Therapeutic Order . GERD, which affects 10-20% of adults in the Western world on a weekly basis,2 is globally understood to be a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications.3 It most commonly presents as heartburn, regurgitation, pain when swallowing, increased salivation, and/or coughing.4 Functionally, it is brought on by an impairment in the lower esophageal sphincter, which can be triggered to open by both hyper- and hypochlorhydria.3 When untreated, GERD may progress to Barrett's esophagus, a precursor of esophageal cancer.4,5
Table 1. The Therapeutic Order1
| 1. Establish the conditions for health | @ Identify and take away disturbing factors
@ Institute a far more healthful regimen |
| 2. Stimulate the healing power nature | @ Recognize the vis medicatrix naturae
@ Expose oneself to patterns, rhythms, forces of nature |
| 3. Address weakened or damaged system/organs | @ Strengthen the immune system
@ Decrease toxicity @ Normalize inflammatory function @ Optimize metabolic function @ Balance regulatory systems @ Enhance regeneration @ Harmonize with one's life force |
| 4. Correct structural integrity | @ Use physical manipulations |
| 5. Address pathology | @ Use specific natural substances, modalities or interventions |
| 6. Address pathology | @ Use specific pharmacological or synthetic substances to preserve life, limb, and function |
| 7. Suppress or surgically remove pathology | @ Essential for preservation of life and limb |
Studies have long shown that GERD can lead to anxious moments and increased levels of stress and fatigue. However, emerging epidemiological studies suggest the association between anxiety and functional disorders of the gastrointestinal tract, including functional dyspepsia and GERD, is actually bidirectional.2, 6, 7 Quite simply, underlying anxiety is a risk factor for developing these conditions.
A case of GERD is presented here that when treated revealed a root cause of the long history of generalized panic attacks . GAD affects as much as 30% of the population, is frequently co-morbid with other health conditions, and is often underdiagnosed and undertreated.8 In this case, optimal therapeutic management and symptom resolution was accomplished by reversing the Therapeutic Order , which established a strong foundation for healing the main cause.
Patient Presentation & History
A 31-year-old Caucasian woman, M.C., given to the Robert Schad naturopathic teaching clinic in May 2023 after being given a diagnosis of GERD from her physician the prior January. She had been prescribed a proton-pump inhibitor and felt some improvement from it, but stopped after 4 months because she was uncomfortable with the idea of standing on pharmaceutical medication indefinitely. Instead, she conducted her own research on natural approaches to GERD, which led to experimentation with dietary changes and self-supplementation with probiotics, digestive enzymes, melatonin, deglycyrrhizinated licorice , slippery elm, and apple cider vinegar.
Noticing an 80% reduction in symptoms with the apple cider vinegar treatment, she was alerted to the possibility that they had hypochlorhydria, and found the clinic seeking medical supervision for any hydrochloric acid challenge make sure a possible prescription for betaine hydrochloride .
The patient began experiencing discomfort in her throat and epigastric region in December 2023. She described this as a tight burning pain in her chest upgrading to her vocal cords, and said she could almost feel the lower esophageal sphincter open at these times. The burning discomfort was often combined with burping. An endoscopic exam to evaluate for Barrett's esophagus along with a urea breath test for Helicobacter pylori were both negative. There were not one other digestive concerns or symptoms. She noticed aggravation after drinking coffee or beer, after eating red meat or fried food. During the time of the very first visit, she was consuming a diet that eliminated self-identified trigger foods, in addition to most dairy products, black tea, and sugar.
She was of normal weight for her height, and with respect to workout, attended yoga class two times a week and walked frequently. She had never smoked, and reported drinking 1-3 alcoholic beverages per week.
Past health background included asthma, that she utilized fluticasone and albuterol inhalers when needed, seasonal allergies, and three spontaneous pneumothoraces as a child. There was no genealogy of gastrointestinal disease; however, depression and anxiety were present on her mother's side. She was happily employed being an elementary school teacher, but the onset of GERD corresponded to several months of your difficult political environment. Regardless of this, the individual said that her stress “wasn't that bad,” and that she decompressed through yoga, reading, and getting together with her partner and friends.
Physical exams revealed a blood pressure level of 120/80 mm Hg, a heartbeat of 80 beats per minute, and a respiration rate of 14 breaths each minute. Bronchovesicular sounds were present on auscultation from the lungs, and resonance was heard. No extra sounds were heard on auscultation from the heart, and S1/S2 was rhythmic and regular. Bowel sounds were present in all 4 quadrants from the abdomen, there was mild guarding on deep palpation from the upper left quadrant. The individual wasn't pale, there was no proof of peeling nails, halitosis, or dilated capillaries evidently, which may indicate severe hypochlorhydria.9
Differential Diagnoses
Clinically, GERD is really a spectrum that can be classified right into a number of syndromes that mirror the different manifestations of reflux disease.4 Patients could be diagnosed according to typical reflux symptoms alone. Differential diagnoses of hernia, esophagitis, and peptic ulcer disease might be ruled out in line with the lab tests ordered by her primary care physician, as well as her noted improvement in symptoms using the proton-pump inhibitor and apple cider vinegar treatment. Our intake and exams supported the existence of “typical reflux syndrome,” defined as the existence of troublesome heartburn and/or regurgitation, epigastric pain, and possible sleep disturbance.4
Management Plan
The patient was extremely organized and well focused throughout the entire first visit. She was conscientious about her health insurance and well continue reading the subject of GERD and the distinction between hypochlorhydria and hyperchlorhydria. She was annoyed by the fact that her physician wouldn't take seriously her suggestion that she may have hypochlorhydria. She was eager to take control of her condition, but simultaneously respectful of the need to have medical supervision moving forward.
When inquired about specific goals, she expected betaine HCl to lead to some 100% decrease in symptoms. Then, she could wean from the supplement and keep her life. Although stress and anxiety as a root cause of GERD were strongly indicated, she was resistant to that suggestion and preferred to focus on HCl supplementation. The HCl challenge test and subsequent betaine HCl supplementation were thus prescribed, using the objective of building rapport and trust using the patient. The actual goal was that physical improvement as well as an ultimate desire to be supplement-free would lead to the patient being available to working through a deeper degree of exploration to be able to remove obstacles to cure, specifically by directly addressing underlying anxiety and stress. Our complete plan for treatment can be seen in Table 2.
Table 2. Successful Turnaround of the Therapeutic Order
| 8. Suppress or surgically remove pathology | @ N/A | |
| January – April 2023 | 9. Address pathology using pharmaceutical or synthetic substances | @ Prescription of proton-pump inhibitor to suppress the signs of GERD |
| May 2023 | 10. Address pathology using natural substances, modalities or interventions | @ Prescription of betaine HCl to address hypochlorhydria as a cause of GERD |
| 11. Correct structural integrity | @ N/A | |
| July – August 2023 | 12. Address weakened or damaged systems or organs | @ Supplement of DGL and slippery elm to support weaning off HCl
@ Botanical prescription of Lavandula angustifolia, Urtica dioica, Passiflora incarnata, and Melissa officinalis to alleviate anxiety at the office and prevent subsequent GERD symptoms |
| July – September 2023 | 13. Stimulate the self-healing mechanisms | @ Acupuncture of Li4, Lv3, and Yintang points to calm the mind |
|
July 2023 – ongoing |
14. Establish the conditions for health | @ Identification of core beliefs and link between thoughts and physical sensations
@ Reprogramming of thoughts that don't serve @ Fine-tuning dieting and exercise for both GERD and stress relief |
Follow-up Visits & Exposing the Root Cause
Follow-up Visits 1 and 2
The first follow-up was 2 weeks after initiation of care. The HCl challenge test revealed that 4-5 tablets of HCl prior to eating led to full resolution of all GERD symptoms. The patient was very pleased. When probed about how experiences at work factored into to her symptoms, she admitted that while food was no longer a trigger, stress at work still was. Six weeks after her initial visit, the patient had tried weaning right down to 2-4 HCl tablets with every meal, and was frustrated that the burning symptoms returned.
Once again, stress was asked about and she admitted that despite being off work for summer time, she had been feeling anxious about returning in September. She screened positive for that questions, “In the past Four weeks are you currently bothered by feeling worried, tense, or anxious?” and “Are you frequently tense, irritable, and achieving sleep problems?” Based on Canadian clinical practice guidelines, these symptoms indicate GAD.8 It had been discussed with her that naturopathic medicine may help address stress, and she or he admitted feeling anxious for as long as she could remember. It was suggested that counseling and/or cognitive behavioral therapy could be used to identify core beliefs. The individual consented to 4 sessions over 8 weeks. The choice is made to combine counseling by having an acupuncture protocol .
Follow-up Visit 3
At the beginning of this follow-up visit , your brain over Mood Anxiety Inventory11 was administered. The patient scored a 20, indicating moderate anxiety. She relaxed in to the acupuncture and quickly paved a route through the “hot thoughts” contributing to her core belief: “If something bad happens, it is indeed my fault, and people will get hurt. This means that i'm not responsible.” This translated into her personal life , as well as her career . She was taught how you can complete a thought record, and inspired to journal her findings over the next 2 weeks.
Follow-up Visit 4
One week later, the patient was discouraged. She had meticulously journaled in her thought record, but tend to not prevent a situation that resulted in a psychological breakdown and severe GERD symptoms. She was frustrated with herself for “not recognizing that she needed help sooner” and for letting her anxiety develop as far as that it had. Like many patients with GAD, her anxiety produced a positive feedback loop resulting in more anxiety. It was affirmed how fast she was making independent revelations about herself and how her thoughts connected to her physical symptoms. She once more expressed a wish to wean off the HCl. It was advised that they try, also it was recommended that they supplement with DGL before meals if necessary.
Follow-up Visit 5
Two weeks later, the individual once again scored a 20 around the Anxiety Inventory. Nevertheless, she reported feeling more empowered and may identify how thoughts linked to sensations in her own body . She recognized that she was becoming emotionally vulnerable and open together with her partner. She was beginning to feel “comfortable with being uncomfortable,” successfully completed exposure-therapy homework, and was dedicated to creating daily mantras to assist reprogram hot thoughts. She revealed that she looked forward to her acupuncture sessions, and located them very calming.
Follow-up Visit 6
At the ultimate session before going back to work , there was a marked alternation in the patient's demeanor and body language. She was open and relaxed, and wondered out loud why she was attracting better energy and smiles from people in the pub. Once the Mind over Mood Anxiety Inventory was re-administered, the patient scored a 12, indicating a shift from moderate anxiety to low anxiety.
Most importantly on her, there had been no instances of GERD, and she or he was down to utilizing only 1 tablet of HCl with large meals, and 2 tablets of DGL if necessary. Although happy with her advancements, she expressed concern that they would fall under old patterns once the school year were only available in September. She was prescribed a tea with equal parts Lavandula angustifolia, Urtica dioica, Passiflora incarnata, and Melissa officinalis in the clinic dispensary, with instructions to steep a pot in the morning and drink it throughout the day when she connected anxious thoughts to physical sensations in her own body.
Follow-up Visit 7
Two weeks later, in mid-September, the individual returned to the clinic and reported 0 episodes of GERD since going back to work 14 days prior. She found this to become remarkable. There was no need to boost the HCl and DGL, and she admitted that although she'd been skeptical that the tea would have much impact on her mood, she thoroughly enjoyed it. Actually, she realized that the smell of the tea alone was a gentle reminder to breathe and ground herself. She was feeling capable and tolerant of all of those other school year, and marveled at the fact that situations that used to send her right into a spiral of repetitive thoughts no longer bothered her.
Discussion
A patient presented with a chief issue for GERD, that was diagnosed based on symptomology4 and lab tests ruling out more severe pathology. The symptoms of GERD resolved with betaine HCl supplementation. However, once the patient attempted to wean right down to a lesser dose, her symptoms returned. Furthermore, regardless of the dose, she only experienced exacerbations during times of stress. This suggested there was a fundamental possible differential diagnosis of GAD. When delivered to the patient's attention through screening8 and also the Mind Over Mood Anxiety Inventory,11 she was prepared to accept the chance that the main reason for her discomfort was anxiety, and opted to continue treatment having a CBT and acupuncture protocol.
Chronic stress, as experienced in GAD, can lead to a disruption in the hypothalamic-pituitary-adrenal axis.12 Chronic stress can also be connected with an elevated chance of hyphchlorhydria.9 Therefore, it's logical to hypothesize that anxiety and stress management can frequently improve GERD brought on by hypochlorhydia. The efficacy and effectiveness of CBT for panic disorders is based on many years of research.13 CBT operates on the model that thoughts, feelings, and behaviors are interrelated. It targets distorted and maladaptive thoughts, and by identifying “hot thoughts,” examining the evidence for and against hot thoughts, challenging and changing maladaptive thoughts, and altering problematic behaviors through exposure therapy, patients can learn to change maladaptive behavior.13
The natural history of GERD remains undetermined.4 The patient responded quickly to betaine HCl supplementation, though her GERD symptoms were not being managed by her current supplementation protocol of just one HCl tablet per day and 2 DGL tablets before large meals. However, the very fact the patient reduced her consumption of HCl so dramatically over the course of 2 months while stress was at an ever-increasing level shows that the majority of her GERD symptoms decreased because of management of her anxiety. Over the course of 4 treatments, the patient moved from the score of 20 to 12 on the Mind Over Mood Anxiety Inventory. As a result, she now experiences a significantly higher quality of life in most respects.
Many new patients visit naturopathic doctors simply wanting to receive a natural option to pharmaceutical treatment. The patient in this case was unaware of the root reason for her GERD, and it is likely more aggressively suggesting that anxiety was the root reason for her symptoms could have overwhelmed her and decreased her compliance with any treatment. As a result, being aware of the Therapeutic Order although not bound to it meant that the patient might be guided via a powerful healing experience that resulted in an amazing improvement in her anxiety, and consequently, almost complete resolution of her GERD. This patient was extremely compliant and dedicated to healing, which contributed to her rapid improvement. She is constantly on the come to the clinic on a monthly basis to reaffirm her mindset and to keep on track with self-care.
Conclusion
Stress is usually indicated in presentations of GERD, but this case evolved in a manner that supports a bidirectional relationship between anxiety and functional gastrointestinal disorders. Naturopathic doctors are trained to observe a hierarchy of healing; traditionally, the Therapeutic Order is what sets them aside from conventional physicians. Although the first goal should be to remove obstacles for stopping in the start of treatment, this patient was not able to acknowledge the presence and significance of her anxiety. This example shows that a practitioner must assess the unique needs and healing requirements from the specific patient and situation, and lends credibility to the principle of modifying the Therapeutic Order at the appropriate interval.
Conflicts of great interest: The writer declares no conflicts of great interest.
Acknowledgements: The writer want to thank the patient on her compliance, honesty, and openness to sharing her story, and Dr Chris Habib, ND, for his supervision and overview of this case study.