GERD is quite common, with the American College of Gastroenterology estimating that nearly 20 percent of the U.S. population is affected by the disease. Research shows that many people living with GERD also have anxiety. A study published in 2018 in the Journal of Neurogastroenterology and Motility, for example, analyzed health data on more than 19,000 people and found that anxiety levels were significantly higher in those with GERD. Another study, published in November 2019 in the journal Cureus, concluded that levels of anxiety are significantly higher in people with GERD, particularly those who report chest pain. Experts say that the relationship between GERD and anxiety is complex and circular. “If you’re in discomfort anywhere in your body, that is stressful,” says Stephen Lupe, PsyD, a gastrointestinal psychologist and director of behavioral medicine in the department of gastroenterology, hepatology, and nutrition at the Cleveland Clinic in Ohio. “And that stress can then exacerbate what’s already going on physically.”

Researchers say that many factors are at play that may explain the association between anxiety and GERD, particularly when it comes to the effects of stress on the gastrointestinal tract. The authors of the Journal of Neurogastroenterology and Motility study describe a few of these underlying mechanisms. The first is that anxiety may decrease pressure on the lower esophageal sphincter, the band of muscle at the bottom of the esophagus that allows food and liquid to pass to the stomach. When this sphincter relaxes abnormally, stomach acid can flow back up through the esophagus, causing heartburn. Stress caused by anxiety may also affect contractions occurring in the esophagus, which propel food toward the stomach. If these contractions become irregular, it can lead to reflux. Finally, high stress and anxiety levels may increase the production of stomach acid. Other research suggests that patients with mental health issues like anxiety may be more sensitive to small changes in their digestive tract. For example, a study published in February 2019 in the journal Surgical Endoscopy examined more than 200 patients who suspected they had GERD. Each patient took a 14-item questionnaire to test for anxiety and depression. Some of the patients had these mental health issues and others did not. Then the researchers observed the pH values in each patient’s esophagus, because an acidic pH value is a common indicator of GERD. They found that nearly half of the patients who reported having anxiety and depression had normal pH values in their esophagus — indicating that they most likely did not have GERD. Were  patients exaggerating the symptoms they felt or feeling symptoms more acutely? Researchers believe it’s the latter. “Patients with anxiety and depression or other mental health issues display a hypervigilance or hypersensitivity to pain sensations,” says study author Fernando Herbella, MD, a gastroenterologist at the Federal University of São Paulo in Brazil.

Psychiatric Disorders and Pain Perception

Vic Velanovich, MD, a gastrointestinal surgeon and another one of the study’s authors, says this is not an isolated phenomenon but part of a broader problem in assessing the severity of disease. “It’s always very difficult to correlate patient-perceived symptoms with actual physiological measures,” he says. Dr. Velanovich offers a neurological explanation. “It’s called the pain modulation network. Pain is converted to electrical signals that travel to the brain. It’s interpreted there by the frontal cortex,” he says. “So anything happening in the frontal cortex, including mental disorders, makes pain perception worse.” However, experts emphasize that this is not the patient’s fault, and it is in no way all in their heads. “This is just how complicated human beings are,” Dr. Lupe says. “As you put the system under stress, there is more dysfunction within the system as a whole, and that means we’re going to interpret the things that are going on in our body as more threatening. That doesn’t mean it’s in your head — those are real problems happening in our body.” He likens it to an engine running at 5,000 revolutions per minute. “There’s nothing wrong with the engine when it starts to have some problems,” he says. “It’s just the stress of running it that high can cause some problems. It’s the same thing inside the human body. That’s why we see stress is linked to all health conditions.”

Tips for Managing GERD and Anxiety

For a patient who suffers from both GERD and anxiety, Lupe says that treatment should focus on caring for the whole person. This includes traditional medical treatments like proton pump inhibitors, antacids, and H2 blockers. “These are treatments that will actually go after anything physically that could be going on with acid dysregulation or dysfunction within the stomach,” Lupe says. Certain lifestyle changes can also help alleviate GERD symptoms:

Avoiding common trigger foods and beverages like fatty or fried foods, citrus, chocolate, mint, garlic, onions, caffeine, and alcoholEating small, frequent mealsMaintaining a healthy weightAvoiding lying down after mealsNot wearing tight-fitting clothingElevating the head of your bedQuit smoking

In addition to these steps to treat physical symptoms, finding ways to manage stress and anxiety should also be part of the treatment plan, Lupe says. These may include cognitive behavioral therapy, mindfulness meditation, relaxation techniques, and hypnosis. “These interventions can reduce the load on the central nervous system and help with the reregulation of detection of symptoms,” Lupe says. “Because if the patient’s detecting things that aren’t necessarily happening due to developed hypersensitivity, the medications [to treat GERD] aren’t going to be as effective.” One of the most important things a patient can do, he says, is be honest with their healthcare team about all of their symptoms. “Tell them what’s going on,” Lupe says. “Anything you can do for your well-being, anything you can do to take care of you, is going to help your body function better as a whole.”