Stress and Anxiety in Gastroesophageal Reflux Disease (GERD)

Introduction to Stress-Induced GERD

Stress and anxiety can trigger and worsen gastroesophageal reflux disease (GERD) symptoms in individuals through the brain-gut pathway, as recognized by the American Gastroenterological Association 1
The bidirectional brain-gut communication pathway plays an important role in all gastrointestinal disorders, including GERD 2

Stress and anxiety can influence the brain-gut axis through neural, hormonal, and immunological pathways that affect normal GI functioning 2
Chronic stress can lead to increased perception of reflux symptoms even without changes in actual acid exposure 1
Anxiety may contribute to behavioral disorders including rumination and supragastric belching, which can worsen GERD symptoms 1

The American Academy of Pediatrics notes that GERD symptoms in children older than 1 year and adolescents often present similarly to adults, with heartburn being a common symptom 3, 4
For most pediatric patients, a history and physical examination without warning signs are sufficient to diagnose uncomplicated GERD and begin treatment 4

Patient education about the brain-gut axis is essential and should be provided early in treatment to help explain how stress and anxiety can influence GERD symptoms 1
For children with GERD and anxiety, a combined approach addressing both the reflux symptoms and the psychological factors may be more effective than treating GERD alone 2
Stress-reducing activities such as mindfulness, relaxation techniques, and diaphragmatic breathing may help reduce GERD symptoms exacerbated by anxiety 1

Children with certain conditions, including neurologic impairment, obesity, history of esophageal atresia, and chronic respiratory disorders are at higher risk for severe GERD and its complications 3, 5
Be alert for warning signs that may indicate more serious conditions beyond simple GERD, including consistently forceful vomiting, abdominal tenderness, or distension 4

Chronic stress and anxiety from PTSD can lead to increased perception of reflux symptoms without actual changes in acid exposure (visceral hypersensitivity) 6
PTSD-related stress can affect GERD through multiple pathways, including altered esophageal motility and reduced refluxate clearance 6

PTSD-related stress can affect GERD through multiple pathways, including changes in intra-abdominal to intra-thoracic pressure gradients, increased transient lower esophageal sphincter relaxations, and reduced protective factors such as salivation and effective peristalsis 6

Stress-reducing activities such as mindfulness, relaxation techniques, and diaphragmatic breathing can help reduce GERD symptoms exacerbated by PTSD 6, 7
Psychological interventions that may benefit patients with comorbid PTSD and GERD include cognitive behavioral therapy, esophageal-directed hypnotherapy, and diaphragmatic breathing exercises 7

Clinicians should be alert to the possibility of PTSD in patients presenting with refractory GERD symptoms 6, 7
Low-dose antidepressants may serve dual purposes of treating both PTSD symptoms and esophageal hypersensitivity 7
Relaxation training has been shown to reduce both symptom scores and esophageal acid exposure in GERD patients 7