Laryngeal reflux disease, pregnancy and phagophobia

Laryngeal reflux disease, often referred to as laryngopharyngeal reflux (LPR), is a complex condition distinct from traditional gastroesophageal reflux disease (GERD), and research over the years has explored its relationship with pregnancy and emerging psychiatric symptoms such as phagophobia (fear of swallowing). Understanding its pathophysiology and clinical impacts in the context of pregnancy and mental health provides valuable insight for healthcare providers and expectant mothers.

What is Laryngeal Reflux Disease?

LPR occurs when stomach contents, including acid, bile, and pepsin, travel backward past the upper esophageal sphincter and irritate the sensitive mucosa of the larynx, pharynx, and, the lungs. Unlike GERD, which primarily involves the lower esophageal sphincter and is marked by heartburn especially when laying down. LPR primarily affects the upper esophageal sphincter, occurs while upright, and may manifest without classic heartburn symptoms. Common symptoms include hoarseness, chronic cough, sore throat, throat clearing, the sensation of a lump in the throat (globus), and excessive mucus.

Laryngeal Reflux During Pregnancy

Pregnancy is a state of profound hormonal and physiological changes that significantly influence gastroesophageal function. Studies and summaries agree that reflux (including LPR) is quite common during pregnancy, affecting more than 50% of expectant mothers, most of whom had no prior reflux symptoms. My own mother developed it back when she was expecting me in the 1960s, but they thought it was down to the copious amounts of oranges she ate during my term.

• Hormonal Influence: Elevated levels of progesterone during pregnancy cause a marked decrease in lower esophageal sphincter pressure (LESP). This relaxation of the LES typically starts in the second trimester, reaching its lowest point near term, then returning to baseline after delivery.

• Physical Pressure: The expanding uterus in later pregnancy increases intra-abdominal pressure, compressing the stomach and promoting upward reflux of gastric contents.

• Gastrointestinal Motility: Delayed gastric emptying and slowed small bowel transit, both consequences of hormonal shifts, further predispose pregnant women to reflux episodes.

Despite its prevalence, severe complications from LPR during pregnancy are uncommon. Patients usually manage cases with diet and lifestyle modifications. Medical intervention starts with antacids and mucosal protectants, and only if necessary, H2-receptor antagonists or proton pump inhibitors, favoring those medications known to be safer in pregnancy.

The Link Between Laryngeal Reflux and Phagophobia

Phagophobia, the fear of swallowing, is a complex psychological disorder that often arises as a reaction to an underlying physical or psychological trigger, notably in patients experiencing persistent throat symptoms. LPR has been shown to produce symptoms, such as throat tightness, globus sensation, and dysphagia (difficulty swallowing), that can mimic or trigger phagophobia anxiety.

• Psychiatric Overlay: Research shows that patients with LPR not only report lower quality of life but also greater psychological distress, with up to 30% reporting anxiety compared to 6% among healthy controls. Successful treatment of LPR can lead to substantial improvements in these psychological indices.

• Diagnostic Challenges: There is significant symptom overlap between LPR, phagophobia, and other psychiatric disorders, complicating diagnosis. Psychiatric comorbidity reduces the validity of commonly used tools such as the reflux symptom index. Clinicians must be vigilant in distinguishing between true reflux-induced dysphagia and psychogenic fear of swallowing, as treatment approaches differ markedly.

• Reflux-Induced Phagophobia: Persistent, untreated LPR can reinforce behavioral fear of eating and swallowing. Conversely, heightened anxiety can amplify perceived reflux symptoms, sometimes in the absence of objective reflux, creating a vicious cycle.

Diagnosis and Management Strategies

LPR remains under-diagnosed and under-treated because of its nonspecific symptoms, frequent overlap with other conditions (including viral infection, allergy, or voice misuse), and lack of standardised diagnostic methods. For pregnant patients, diagnosis is primarily clinical; radiologic assessments (like barium swallow) are avoided because of fetal risk. Endoscopic procedures may be used for refractory cases.

• In pregnancy, lifestyle modifications - such as eating small, frequent meals, avoiding trigger foods, and remaining upright after eating. Also, be open to a variety of different foods to start with. One client hadn’t eaten in 6 weeks and was worrying about the amount of weight lost. By drinking protein shakes and being able to eat foods like mashed potatoes, scrambled eggs, and soup, she could start gaining weight.

• Your doctors must cautiously approach pharmacologic therapy, prioritising safety for both mother and fetus.

• Using relaxation methods such as meditation and hypnotherapy can help calm down sensations and help the person to swallow again.

Conclusion

Laryngeal reflux disease presents unique diagnostic and therapeutic challenges, especially within the context of pregnancy and coinciding psychiatric symptoms like phagophobia. Pregnancy-related hormonal shifts and physical changes strongly influence its occurrence. For patients experiencing both LPR and swallowing anxiety, interdisciplinary care is crucial, underscoring the need for further research and standardised diagnostic guidelines to improve maternal and mental health outcomes.

At scared2swallow, we’re happy to help clients who saw their health professionals and were prescribed the correct medication and advice. Our intervention is about the psychological impact the fear of swallowing has and helps our clients to think more rationally and overcome the problems.