Can anxiety increase acid reflux symptoms in adults with a history of both conditions?

Can Anxiety Increase Acid Reflux?

Yes, anxiety can significantly increase acid reflux symptoms, though it primarily affects symptom perception and severity rather than actual acid exposure in most cases. 1, 2

The Brain-Gut Axis Connection

The relationship between anxiety and GERD operates through the bidirectional gut-brain axis, which connects psychological states to gastrointestinal function. 1 This mechanism explains why anxiety doesn't necessarily cause more acid reflux episodes, but profoundly influences how patients experience and report their symptoms.

Key Mechanisms:

• Visceral hypersensitivity: Anxiety increases awareness and sensitivity to normal esophageal sensations, making low-intensity stimuli feel like painful reflux symptoms 1, 2
• Hypervigilance: Anxious patients become preoccupied with bodily sensations, amplifying symptom perception 1
• Stress-induced symptoms: The autonomic nervous system and HPA axis dysregulation can impair gut function, though this doesn't always translate to measurable increases in acid exposure 1, 2

Clinical Evidence

The most compelling research demonstrates that stress tasks significantly increase subjective reflux symptom reports without increasing objective acid exposure parameters (total acid exposure, number of reflux episodes, or duration of episodes). 2 This finding has been replicated, showing that while psychological stress elevates blood pressure, pulse, and anxiety ratings along with reflux symptom reports, it does not proportionally increase measurable acid reflux. 2, 3

Patients with chronic anxiety traits are particularly vulnerable, maintaining high reflux symptom ratings during all stress periods, while non-anxious patients show decreased symptoms over time. 2

Prevalence Data:

• 44.1% of GERD patients have abnormally high anxiety scores (HADS >7) 4
• 23.8% have abnormally high depression scores 4
• Anxiety and depression are three times more common in patients with GERD compared to healthy controls 1
• The most distressed subgroup consists of patients without surgical indications, where 47.9% have significant anxiety 4

Impact on Symptom Severity

Elevated anxiety scores significantly correlate with increased severity of heartburn, fullness, and dysphagia, independent of objective acid measurements. 4 This relationship is particularly pronounced in:

• NERD patients with negative pH monitoring (NERD-SI- subgroup), where anxiety and depression scores are significantly higher than in patients with objective acid reflux 5
• Patients with refractory GERD symptoms, where psychological factors often explain persistent symptoms despite adequate acid suppression 1

Clinical Implications for Management

Initial Assessment:

When evaluating GERD patients, specifically assess for anxiety, stress-induced symptoms, and behavioral patterns that suggest visceral hypersensitivity. 1 The 2022 AGA guidelines explicitly recommend identifying these factors during symptom characterization to guide appropriate therapy selection. 1

Treatment Approach:

Integrate stress-reduction strategies from the initial visit, as patient education about the brain-gut axis empowers patients and opens pathways for psychological interventions. 1 Specifically:

• Provide standardized education on the brain-gut axis relationship at the first clinic visit 1
• Encourage mindfulness and stress-reducing activities as part of routine GERD management 1
• Consider relaxation training, which has been shown to significantly reduce both symptom reports AND total esophageal acid exposure compared to placebo interventions 3

When Anxiety Dominates:

For patients with refractory symptoms despite adequate PPI therapy, recognize that anxiety and depression may be the primary drivers rather than ongoing acid reflux. 1, 5 In these cases:

• pH/impedance monitoring helps differentiate true refractory reflux from functional heartburn with anxiety-driven symptom amplification 1
• Psychological interventions become essential, including cognitive behavioral therapy strategies to address maladaptive beliefs and hypervigilance 1
• Anxiolytic therapy or low-dose amitriptyline may be beneficial 1

Common Pitfalls

Do not assume that severe symptoms always correlate with severe acid exposure. 1, 2 The moderate correlation between reflux symptoms and esophageal acid exposure means that highly anxious patients may report debilitating symptoms with minimal objective reflux, while others with significant acid exposure may be minimally symptomatic. 1, 5

Avoid over-escalating PPI therapy in anxious patients with refractory symptoms without objective testing, as this rarely improves outcomes and misses the underlying psychological component. 1

Recognize that belching complaints are more commonly associated with anxiety, particularly supragastric belching, which occurs in up to 3.4% of patients with upper GI symptoms. 1 This behavioral pattern often coexists with GERD and anxiety.

Quality of Life Impact

Refractory GERD symptoms driven by anxiety significantly impair quality of life, reducing physical health-related QOL by 8-16% and mental health-related QOL by 2-12%. 1 Sleep disturbance is the major impact, which creates a vicious cycle of emotional stress and decreased work performance. 1 Addressing the anxiety component is therefore critical not just for symptom control but for overall patient well-being.