A study in The American Journal of Gastroenterology found that people who did not get heartburn symptom relief from standard treatments but did not have detectable reflux tended to experience more distress and have a poorer quality of life, while symptoms for those with diagnosed gastroesophageal reflux disease who did not respond to proton pump inhibitors were associated with reflux severity. Researchers said the study shows the association between psychosocial factors and symptoms among people with normal physiology who do not respond to PPIs.