Stress and reflux - the evidence

As a cause:

It is a general perception that 'stress' makes reflux symptoms worse. It has been proposed that this is due, at least in part, to 'dysmotility'. In a study from Belfast in 1996 however it was shown that during both acute physical and psychological stress there were changes in motility only in patients with ERD, not in the group with NERD. A group from the Netherlands looked at a group of patients with ERD before and after endoscopically proven healing of their oesophagitis and found that both motility and oesophageal acid exposure (% time pH < 4, number of reflux episodes) did not change after healing of oesophagitis, thus implying that acid clearance remained unchanged. This suggests that impaired motility in reflux oesophagitis is either an irreversible consequence of oesophageal inflammation, or a pre-existing factor in its pathogenesis. Interestingly, individuals subjected to psychological stress report worse symptoms of heartburn but do not have an increased number of reflux episodes. This would account for the low response rates to traditional treatments that is observed.

Hot drinks are known to worsen reflux and a series of studies have confirmed that exposure to heat or psychological stress increases the permeability of the oesophgaeal mucosa. This makes ingress of the refluxate into the lamina propria a possibility and thus may represent one of the first pathogenic events in the development of reflux disease.

Acute auditory stress can exacerbate heartburn symptoms in reflux patients by enhancing perceptual response to intra-oesophageal acid exposure. This greater perceptual response is associated with greater emotional responses to the stressor by the subject. Recently it has been shown that there is a genetic predisposition to functional heartburn in patients who are heterozygote for a sub-unit of the GABA-A (GABRA6) receptor gene - these individuals are more than twice as likely to have high symptom scores and display higher levels of neuroticism and lower extroversion scores.

Does removal/avoidance help?

Subjects who receive relaxation training have significantly lower reflux symptom scores and total oesophageal acid exposure times than subjects who do not. This suggests that whilst stress worsens symptom perception, its removal may help both this perception and reduce total reflux time. There are case reports of hynotherapy succesfully treating patient with functional heartburn (ie: normal endoscopy and pH studies).