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Behavioral Treatment of Chronic Belching Due to Aerophagia in a Normal Adult

Article  in  Behavior Modification · June 2006

DOI: 10.1177/0145445504264746 · Source: PubMed

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BEHAVIOR
10.1177/0145445504264746
Cigrang et al.MODIFICATION
/ BEHAVIORAL TREATMENT
/ Month Year OF CHRONIC BELCHING

Behavioral Treatment of
Chronic Belching Due to
Aerophagia in a Normal Adult

JEFFREY A. CIGRANG
Wright-Patterson Medical Center, Ohio

CHRISTINE M. HUNTER
ALAN L. PETERSON
Wilford Hall Medical Center, Lackland Air Force Base, Texas

Aerophagia, or excessive air swallowing, is a potential cause of belching, flatulence, bloating,

and abdominal pain and may contribute to a worsening of gastrointestinal (GI) disorders. A lim-
ited number of published reports of aerophagia treatment indicate that behavioral methods may
be of benefit. A case report is presented describing the behavioral treatment of chronic belching
due to aerophagia in an adult female. The collaborative application of single-participant design
research helped identify open-mouth, diaphragmatic breathing and minimized swallowing as an
effective intervention. Belching frequency was reduced from an average rate of 18 per 5-min
interval during the baseline period to 3 per 5-min period after treatment. Results were maintained
at an 18-month follow-up. Recommendations for the use of a brief treatment protocol with adults
referred for chronic belching or other GI complaints attributed to aerophagia are discussed.

Keywords: behavioral treatment; aerophagia; gastrointestinal disorders

INTRODUCTION

Aerophagia introduces excessive air into the esophagus or stomach

and is considered a potential cause of belching, flatulence, bloating,
and abdominal pain that may contribute to a worsening of gastrointes-
tinal (GI) disorders (Calloway, Fonagy, & Pounder, 1982). Aero-
phagia has been commonly divided into two types. One type is re-
ferred to as deliberate air gulping and is primarily seen in individuals

AUTHORS’ NOTE: The views expressed in this article are those of the authors and are not the
official policy of the Department of Defense or the U.S. Air Force.
BEHAVIOR MODIFICATION, Vol. 27 No. X, August 2004 1-11
DOI: 10.1177/0145445504264746
© 2004 Sage Publications

1
2 BEHAVIOR MODIFICATION / Month Year

with profound retardation, where it is viewed as a self-stimulatory or

attention-seeking behavior (Holburn, 1986). The prevalence of air
gulping in institutions for those with mental retardation is estimated to
be 2.7% (Danford & Huber, 1981). In the normal adult population,
aerophagia is referred to as excessive air swallowing and, in the
absence of any physical etiology, is presumed to be associated with
stress or anxiety (Talley, 2000). Increases in the rate of spontaneous
swallowing in response to laboratory stressors have been demon-
strated in both an asymptomatic sample (Fonagy & Calloway, 1986)
and a sample of individuals who had sought assistance for GI symp-
toms (Cuevas-Becerini, 1995). A contradictory finding was reported
by Whitehead, Chami, Crowell, and Schuster (1991), who found
spontaneous swallowing frequency as measured by neck EMG activ-
ity to be unrelated to a self-report measure of psychiatric symptoms in
373 consecutive patients referred for evaluation of upper GI symptoms.
Medical guidelines recommend that aerophagia be considered in
patients who complain of chronic belching (Suarez & Levitt, 2002). A
diagnosis of aerophagia is indicated by repetitive belching after other
physical etiologies such as esophageal motility problems have been
ruled out (Talley, 2000). Behavioral treatment of aerophagia has
received relatively little attention from researchers (Whitehead,
1992). Published research on the treatment of air gulping in the popu-
lation of those with mental retardation is limited to a handful of case
studies, published in the 1980s, that reported mixed success using
behavioral interventions with adults (Holburn & Dougher, 1985,
1986) and children (Barrett, McGonigle, Ackles, & Burkhart, 1987).
One report (Flaisher, 1994) described the treatment of aerophagia in
two 4-year-old children without mental retardation. In one child, the
aerophagic behavior was completely eliminated after 4 weeks using a
combination of suggestions, covert desensitization, and positive rein-
forcement for nonaerophagic behavior. The second child did not show
any improvement in aerophagia in response to a similar intervention.
A second strategy was to teach him a response incompatible with
swallowing (bend forefinger and bite slightly on it for 2-3 s). The par-
ents were instructed to implement daily practice sessions at home. A
clinically significant reduction in air swallowing was achieved after 6
months of treatment.
 Cigrang et al. / BEHAVIORAL TREATMENT OF CHRONIC BELCHING 3

The literature on behavioral treatment of aerophagia in normal

adults is limited to two publications. One older case study described
the use of self-administered response-contingent shock to reduce the
frequency of belching in a 28-year-old male with a 10-year history of
aerophagia (Rinn & Jackson, 1974). Frequency of belching was
reduced from a range of 19 to 23 per 5-hr period at baseline to a range
of 2 to 12 during the intervention. These results were maintained at 3-
and 6-month follow-up periods. A more recent study randomly assigned
12 patients with hiatus hernias, who had high rates of spontaneous
swallowing, to receive one of two behavioral interventions (Calloway,
Fonagy, Pounder, & Morgan, 1983). One group of patients received
training in progressive muscle relaxation and was instructed in the use
of a portable galvanic skin response biofeedback device for home
practice. No specific directions were given to reduce air swallowing.
The second group was instructed in self-control strategies for reduc-
ing the frequency of spontaneous swallowing. Strategies included
breathing techniques, yawning, keeping the mouth open, and other
behaviors intended to interfere with the swallowing reflex. Ten partic-
ipants completed the 4-week treatment program, and most demon-
strated a decline in rate of spontaneous swallowing at posttest. There
was also indication at posttest of improvements in hiatus hernia symp-
toms, but these were not maintained at a 9-month follow-up period.
In sum, published reports of the treatment of aerophagia in routine
clinical practice are limited. Evidence to date suggests that frequency
of swallowing and belching are amenable to change via behavioral
intervention. The current case report presents a description of the
behavioral treatment of chronic belching due to aerophagia in an adult
woman with no concomitant physical health problems. The therapist-
patient collaboration in the use of single-participant research design
to test various interventions makes the case unique and informative.

CASE PRESENTATION

The patient was a 38-year-old, married African American woman

on active duty in the U.S. Air Force who experienced a sudden onset of
persistent belching. The patient reported that the onset of belching
4 BEHAVIOR MODIFICATION / Month Year

occurred during a required aerobic fitness evaluation on a stationary

bike approximately 6 months prior to her referral. While exercising,
she experienced tachycardia and stopped pedaling. She then focused
on taking deep breaths in an effort to slow her heart rate down and also
drank a glass of water. Although her heart rate returned to normal after
several minutes of rest, she developed a hiccup that persisted over the
next several days and then progressed to chronic belching. After 3
weeks of continued belching, she sought out a medical evaluation at
her primary care clinic. Over the next several months, her primary care
physician prescribed a series of medications that proved unhelpful in
reducing the belching. The medications included an H2 blocker, a
motility agent, an antiemetic, an antidepressant, and an antipsychotic.
She underwent an upper GI study that showed no abnormalities. At
one point, she was encouraged to attend a stress management class but
did not follow through. The patient was then consulted to an internist,
who concluded that the belching was the result of excessive air
swallowing and referred her to the Clinical Health Psychology (CHP)
service.
In the first session, the patient described the belching as occurring
frequently (several times a minute) and causing her significant frustra-
tion and embarrassment. There were no other GI complaints (no
increase in flatulence or nausea) apart from occasional feelings of
pressure in her stomach that were relieved by belching. The occur-
rence of belching in public settings such as work meetings and riding
in elevators was particularly frustrating for her. She noted that the
belching did not occur when she was talking or while she was asleep.
Otherwise, she could not identify any pattern to the belching. For a
period of time prior to her referral, she had monitored her diet but was
unable to identify any connection between belching and food type.
The patient expressed a willingness to be seen by a psychologist,
although she was uncomfortable with the implication that the problem
was all in her head. The patient was concerned that some physical
pathology had been overlooked as the cause for the persistent belch-
ing. She also did not place much confidence in the internist’s conclu-
sion that she was swallowing excessive air. The psychologist (first
author) was moderately successful in establishing a collaborative and
problem-solving approach with the patient. Therapy was presented as
 Cigrang et al. / BEHAVIORAL TREATMENT OF CHRONIC BELCHING 5

a joint effort of analyzing the problem and identifying possible behav-

ior changes that could lead to symptom improvement.
The patient was asked to self-monitor the belching between the first
and second session. She was given a 7-day symptom diary and
instructed to record the number of spontaneous belches in a 5-min
period on four occasions each day (before breakfast, lunch, dinner,
and bedtime). She was diligent in completing the homework and
brought the results to the second session. The average frequency of
belching for the week was fairly consistent across the course of her
workday (range 18-19 per 5-min period) and then tended to be lower
in the evening at bedtime (12). In discussing the trend for lower fre-
quencies in the evenings, the patient noted that she generally felt more
relaxed in the evening than the daytime hours.
In the second session, we implemented an ABACAD single-partic-
ipant research design to further establish a baseline (A) and to evaluate
the effects of several interventions (Kazdin, 1982; Morgan & Morgan,
2001). The time period for the baseline and intervention conditions
was 5 min. For the first intervention (B) the patient was asked to pur-
posefully swallow once at each 30-s interval. During the second inter-
vention condition (C) the patient was not to swallow. She was given a
cup to spit into as needed. In preparation for the third intervention con-
dition (D), the patient was taught a simple exercise involving easy,
relaxed diaphragmatic breathing through her nose with her mouth
closed. She was asked to implement the breathing exercise during the
last intervention period. Throughout the ABACAD design, the patient
was to self-monitor the frequency of belching by making hash marks
on paper. These were then tallied and the results are presented in
Figure 1.
The baseline frequencies obtained in session were similar to the
baselines from the patient’s home-monitoring record. Purposeful
swallowing appeared to increase the frequency slightly. The most dra-
matic effect was seen in the no-swallowing condition, which reduced
the frequency of belching to near zero. This result appeared to be con-
vincing evidence that the belching was related to air swallowing. Dia-
phragmatic breathing resulted in a decline of approximately two
thirds from the baseline condition. In discussing these results with the
patient, she was encouraged by the effects of diaphragmatic breathing
6 BEHAVIOR MODIFICATION / Month Year

24
25

22
21

20
18

15

10

0
A B A C A D
Baseline Purposed Baseline No Sw allow ing Baseline Diaphragmatic
Sw allow ing Breathing Via
Nose

Figure 1. Belching frequency results from ABACAD single-case research design in sec-
ond therapy session.

and agreed to practice the intervention in the coming week and moni-
tor the effect.
The patient brought the week’s self-monitoring results to the third
session. The previous in-session effects of relaxed breathing on belch-
ing frequency showed a good generalization to the patient’s day-to-
day life. The week’s average 5-min belching frequency with diaphrag-
matic breathing ranged from 6 to 8. However, in reviewing the data
with the patient, she voiced concern that the results meant that the
belching was a “voluntary” response to life stress and implied that she
was “doing it to herself.” The psychologist suggested the hypothesis
that the symptoms were the result of a learned habit of excessive air
swallowing and not part of a stress response. The patient expressed
frustration that the belching was persisting, although now at a reduced
 Cigrang et al. / BEHAVIORAL TREATMENT OF CHRONIC BELCHING 7

rate, when she was able to maintain diaphragmatic breathing. The

third session concluded with a presentation of cue-controlled relax-
ation (i.e., identification of commonly encountered stimuli that could
serve as reminders to practice relaxed breathing).
In between the third and fourth session, a radiological swallowing
study was scheduled for the patient with a speech pathologist. This
was partially in response to the patient’s continued concern that some
physical pathology was contributing to the belching. The results did
not identify any abnormalities. The patient also practiced diaphrag-
matic breathing and minimized swallowing during a work staff meet-
ing. Frequency of belching was 5 during the 5-min intervention,
reduced from a baseline level of 21.
At the fourth session, the patient reported a significant reduction in
belching frequency in the preceding week after consuming a drink
mix that she obtained as part of a starch-blocker diet. We agreed to
conduct an experiment in the upcoming week to better evaluate the
effects of the drink mix. The patient self-monitored the frequency of
belching following the consumption of different liquids, including the
diet drink mix, on different days of the week but similar times and
amount. At a phone follow-up later in the week, the patient reported
no advantage to the diet mix in comparison to the other liquids, and the
frequencies were similar to baseline.
The fifth session focused on a review of the progress to date and
further supervised practice of a relaxation response including behav-
ioral relaxation posture. The progress to date was summarized by
emphasizing that two behavioral changes (a relaxed breathing pattern,
decreased swallowing frequency) resulted in a significant decline in
rate of belching but not a complete cessation. The psychologist was
moving out of the area, and the patient expressed a preference for a
referral to another CHP provider who would continue treatment.
The patient was seen by another psychologist (second author) for
three additional therapy sessions. In the first session, a suggestion to
alter the relaxed breathing to be open- versus closed-mouth was evalu-
ated and appeared to be helpful. The patient agreed to practice open-
mouth breathing between sessions while recording belching fre-
quency in a similar manner as previous self-monitoring. A review of
the data at the following session showed an average of three belches
8 BEHAVIOR MODIFICATION / Month Year

per 5-min period across the 7 days. This was the best outcome to date.
The patient was pleased with the results but continued to be somewhat
skeptical that excessive swallowing was the sole cause of the belching.
The patient expressed concern that she was unaware of any excess
swallowing. After some discussion, the psychologist suggested the
patient experiment with different body positions (e.g., sitting, lying
down, with legs elevated, etc.) to see if she could find a posture where
her swallowing did not lead to belching and to increase her sensitivity
to when she was swallowing excess air.
In the final session, the patient reported no success in finding a pos-
ture that led to less belching. However, she reported continued benefit
from practicing relaxed breathing from her mouth. She had begun to
use increased belching as a cue to implement mouth breathing and
was trying to make it a habit. She noted that her spouse and children
had all noticed the decrease in belching. The patient and psychologist
agreed that she had reached the maximum benefit from the CHP clinic
and agreed to discontinue therapy. She was encouraged to continue
working on building mouth breathing into her daily routine.
Approximately 18 months after her last session, the patient was
contacted by phone. She reported maintenance of effects for the
behavioral interventions observed at the end of therapy but no further
improvement. She stated that she had resigned herself to live with the
inconvenience of the belching.

DISCUSSION

Figure 2 summarizes the positive effects of the behavioral treat-

ments compared to baseline levels. From a clinical perspective the
interventions resulted in significant reductions in the targeted symp-
tom. This outcome was achieved through instruction and coaching in
minor alterations in breathing habits over a relatively brief period of
time (8 sessions). From the patient’s standpoint, the therapy was
clearly helpful but did not meet her expectations for achieving a com-
plete cessation of a frustrating problem. One and a half years after
therapy was discontinued the patient reported symptom persistence
albeit at a greatly reduced level. This outcome is similar to previous
 Cigrang et al. / BEHAVIORAL TREATMENT OF CHRONIC BELCHING 9

20
19
18 18
18

16

14
12
12
Baseline
10 Intervention 1
Intervention 2
8 8
8
7
6
6

4 3 3 3 3
2

0
Breakfast Lunch Dinner Bedtime

Figure 2. Comparison of 7-day averages of self-monitoring of belching frequency for

baseline and two intervention conditions.
NOTE: Intervention 1 = relaxed diaphragmatic breathing with mouth closed; Intervention 2 =
relaxed diaphragmatic breathing with mouth open.

reports (Flaisher, 1994; Rinn & Jackson, 1974) showing meaningful

reductions but not a complete elimination of aerophagic behavior in
treated patients.
The collaborative nature of the therapy, the patient’s diligent self-
monitoring, and the application of single-participant research design
helped to quickly identify efficacious interventions. In particular, the
flexible nature of single-participant research methods that Hayes
(1998) referred to as “investigative play” showed a very good fit with
the current case study. The therapists and patient worked together to
assess the problem behavior, identify potential solutions, evaluate the
interventions, and then collaboratively adjust the course of therapy
based on the data collected. This flexible, problem-solving approach
can sometimes be missing from treatments that emphasize the use of
10 BEHAVIOR MODIFICATION / Month Year

manualized interventions derived from group comparison research. In

addition, this study highlights the potential benefits of direct behav-
ioral observation and frequency count of overt behaviors within
treatment sessions.
Although the behavioral literature on treatment of aerophagia is
still limited, there appears to be sufficient evidence now to recom-
mend a brief treatment protocol for helping adults without mental
retardation who are referred for chronic belching or other GI com-
plaints attributed to aerophagia. In-session use of single-participant
research designs can help validate for the clinician and the patient that
excessive air swallowing is contributing to the GI symptoms. Single-
participant designs, in turn, can assist in quickly evaluating the useful-
ness of different behavior changes in altering symptom occurrence.
Instructions in relaxed breathing combined with an incompatible
response such as keeping the mouth open are likely to result in signifi-
cant reductions in symptom occurrence. Establishing an atmosphere
of collaboration will then be a resource in helping the patient general-
ize the skills learned in session to day-to-day life. Finally, complete
cessation of problematic symptoms may not be achieved with a brief
intervention. Further reductions in symptoms may require greater
creativity and patience on the part of both the therapist and the patient.

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Jeffrey A. Cigrang obtained his Ph.D. in clinical psychology from the University of Mem-
phis and completed postdoctoral training in clinical health psychology at Wilford Hall
Medical Center in San Antonio, Texas. He is presently a member of the internship train-
ing faculty at Wright-Patterson Medical Center in Dayton, Ohio.

Christine M. Hunter obtained her Ph.D. in clinical psychology from the University of
Memphis and completed postdoctoral training in clinical health psychology at Wilford
Hall Medical Center in San Antonio, Texas. She is currently serving on the faculty for the
internship and postdoctoral training at Wilford Hall Medical Center.

Alan L. Peterson, Ph.D., ABPP, is the chair of the Department of Psychology and director
of the clinical health psychology postdoctoral fellowship program at Wilford Hall Medi-
cal Center in San Antonio, Texas. He actively teaches the use of single-participant design
research during the supervision of psychology interns and postdoctoral fellows.

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