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WHY CAN ANXIETY DISORDERS CAUSE GASTROESOPHAGEAL REFLUX SYMPTOMS TO PERSIST?
Have you taken reflux medication, but your symptoms still haven't improved?
"I've been taking medication for nearly 3 months, but I still have a burning sensation behind my breastbone."
"Every time I'm stressed, the globus sensation and heartburn reappears."
"My endoscopy results are normal, but I still have a burning pain in my chest.”
Dr. Mai Vien Phuong, Master’s Degree, Head of the Gastrointestinal Endoscopy Unit at the American International Hospital (AIH), stated that these are common situations doctors encounter when examining patients with gastroesophageal reflux disease (GERD). Many people worry that their treatment is no longer effective or that their condition has become severe. However, in many cases, the cause of persistent symptoms stems not only from gastric acid levels but is also related to the patient's psychological state.
According to Dr. Phuong, increasing scientific evidence shows a strong link between anxiety disorders and GERD. These two conditions can interact, creating a pathological vicious cycle: anxiety increases the perception of uncomfortable reflux symptoms, while persistent symptoms cause patients to become even more stressed and anxious.
Therefore, for effective treatment, alongside controlling gastric acid, doctors also need to evaluate factors such as stress, sleep, and lifestyle to develop a comprehensive treatment plan for each patient.
Reflux and Anxiety: Seemingly Unrelated Conditions That Mutual Influence Each Other
GERD occurs when gastric acid flows back up into the esophagus, causing symptoms such as:
Heartburn.
Acid regurgitation.
Retrosternal burning sensation.
Difficulty swallowing.
Persistent cough.
Hoarseness.
Meanwhile, anxiety disorder is a condition where individuals experience frequent stress, restlessness, excessive worry, and difficulty controlling negative thoughts.
At first glance, these two conditions belong to different medical specialties. However, the digestive system and the brain constantly communicate with each other through what is known as the “brain-gut axis”. When psychological states change, the activity of the esophagus and stomach can also change accordingly.
What do scientific studies show?
A study published in the Middle East Journal of Digestive Diseases compared individuals with GERD to a healthy control group using anxiety and depression rating scales.
The results showed that people with GERD had a significantly higher rate of anxiety and depression disorders compared to those without the condition. In particular, the group with non-erosive reflux disease (NERD) - who have reflux symptoms but no clear esophageal damage on endoscopy - tended to experience more psychological issues.
This indicates that the discomfort experienced by patients depends not only on the amount of refluxed acid but is also influenced by how the nervous system perceives and processes pain signals.
Why does anxiety worsen reflux symptoms?
1. The esophagus becomes more sensitive
Imagine two people touching an object with the same temperature.
One person only feels a slight warmth.
The other feels a burning sensation.
The same thing can happen with the esophagus. When anxiety persists, the nervous system becomes more sensitive to minor stimuli. Even a small amount of acid can create an intense burning sensation.
This phenomenon is known as esophageal hypersensitivity.
When anxiety persists, the nervous system becomes increasingly sensitive to even the slightest stimuli.
2. The brain “amplifies” the discomfort
When under prolonged stress, the brain tends to focus more heavily on bodily signals.
Sensations that are normally very mild - such as slight bloating, a single burp, or a minor discomfort after a meal - can be perceived much more intensely than usual.
As a result, patients are prone to thinking that their condition is worsening, even though endoscopy or esophageal pH monitoring results show little to no change.
3. Stress alters lifestyle habits
Anxiety also causes many people to:
Eat irregularly.
Eat too quickly.
Stay up late.
Drink a lot of coffee.
Smoke.
Consume alcohol.
Exercise less.
These are all factors that can make reflux symptoms appear more frequently.
When should you consider the factor of anxiety?
If you have one or more of the following signs, your doctor may consider evaluating psychological factors further:
Endoscopy results are mostly normal despite persistent symptoms.
Symptoms show very little improvement even with proper medication.
Symptoms noticeably worsen whenever work or family pressure increases.
Accompanied by insomnia, palpitations, rapid heartbeat, or a constant feeling of stress.
This does not mean the symptoms are “imagined”. On the contrary, patients genuinely experience real discomfort; it is simply that the mechanism causing the symptoms involves the central nervous system.
Treatment involves more than just taking acid-reducing medication
Acid-suppressive medications (PPIs) remain the cornerstone of GERD treatment. However, for some individuals, simply reducing acid is not enough.
If anxiety contributes to worsening symptoms, doctors may combine various approaches, such as:
Lifestyle modifications.
Psychological counseling.
Stress management.
Relaxation training.
Treating anxiety disorders when indicated.
In special cases, using low-dose neuromodulators as directed by a specialist.
The goal is not only to reduce acid levels but also to help the nervous system become less sensitive to stimuli from the esophagus.
The treatment goal is not only to reduce acid levels but also to help the nervous system become less sensitive.
Dr. Mai Vien Phuong, Head of the Gastrointestinal Endoscopy Unit at the American International Hospital (AIH), shared the case of a 42-year-old male patient working in business who came for an examination due to a retrosternal burning sensation lasting for over a year.
“The patient reported that symptoms typically appeared more frequently before important meetings or during periods of intense work stress. Although he had undergone endoscopy twice, the results only showed mild esophagitis, and despite adhering to medication treatment, the heartburn kept recurring,” he shared.
Through the examination and a thorough medical history evaluation, the doctor noted that the patient's symptoms decreased significantly during low-stress periods, such as during vacations or when his workload decreased. Alongside GERD treatment, the patient was advised to adjust his sleep schedule, maintain regular exercise, and apply stress management techniques.
“After a few months, the frequency and severity of heartburn decreased significantly, his sleep quality improved, and the patient felt much more comfortable in his daily life.”
According to Dr. Phuong, this is an example showing that GERD treatment should not only focus on controlling gastric acid but also requires a comprehensive assessment of lifestyle and mental health factors. When these factors are improved, treatment outcomes are typically more positive, and patients enjoy a better quality of life.
What should patients do?
If you have GERD, you should:
Take your medication exactly as prescribed by your doctor.
Do not arbitrarily increase or change your medication when symptoms do not improve.
Eat slowly, avoid overeating, and do not lie down immediately after a meal.
Limit alcohol, tobacco, and foods that easily trigger reflux.
Maintain a healthy weight.
Get enough sleep and exercise regularly.
Share with your doctor if you frequently experience stress, insomnia, or anxiety.
Properly managing your mental health can help improve your quality of life and support more effective reflux treatment.
Conclusion
Dr. Mai Vien Phuong emphasized that GERD is not simply a disease of the stomach or esophagus. In many patients, factors such as stress, anxiety, and sleep disorders can contribute to prolonged symptoms and affect treatment efficacy.
“Anxiety is not the sole cause of reflux, but it can make patients perceive symptoms more clearly, feel more uncomfortable, and easily fall into a vicious cycle between pathology and psychology. Therefore, treatment requires a comprehensive approach, focusing not only on controlling gastric acid but also on mental health and lifestyle,” he stated.
At the Department of Gastroenterology, American International Hospital (AIH), patients undergo comprehensive examination and evaluation to accurately determine the cause of their symptoms, thereby establishing a appropriate treatment regimen tailored to each individual. Alongside medication therapy when necessary, the team of doctors also provides guidance on nutrition, lifestyle, and psychological factors to help patients effectively manage GERD and improve their quality of life.
If you frequently experience heartburn, a burning sensation behind the breastbone, difficulty swallowing, or prolonged symptoms despite treatment, please consult a gastroenterologist for a thorough evaluation. Accurate diagnosis of the cause and comprehensive treatment are the keys to effectively controlling the disease and minimizing recurrence.
References
Jansson C, et al. Anxiety and Depression in Patients with Gastroesophageal Reflux Disorder. Middle East Journal of Digestive Diseases. 2017.
Katz PO, et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease.
Rome Foundation. Disorders of Gut–Brain Interaction.
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