health stress mang

The Relationship between Stress and Gastroesophageal Reflux Disease

Western Oregon University

Mind/Body Health

Introduction

Gastroesophageal Reflux Disease, or GERD, is a condition in which the contents of the stomach backtrack into the esophagus, causing heartburn, nausea, burning in the esophagus, worse symptoms at night, etc. and can lead to esophageal ulcers, weight loss, constricted airways, bleeding, or may mimic heart pain. Because of the pepsin usually contained in the fluid that backs up into the esophagus, this condition can sometimes lead to holes in the esophagus, as pepsin is an enzyme meant to break down the proteins in food for digestion, and sometimes bile from the duodenum of the small intestine will back up. In some cases, GERD can cause fluid storage in the middle ear and sinuses, leading to other complications. The common causes associated with GERD are slow emptying of the stomach, acidic food and beverage consumption, and abnormal esophagus contractions. Common treatment for GERD consists of being propped up while sleeping in order to let gravity keep pulling food down, diet changes, proton pump inhibitors, histamine blockers, and antacids.

Up until recently, GERD was associated with lifestyle choices and changes, esophageal conditions, and potential intestinal issues, but recently there has been speculation that, much like coffee and cigarettes, stress is a factor in making episodes of GERD worse. What professionals are intending to unravel is whether or not the psychological experience of perceived stress is really linked to pain receptors in the brain that activate the acid in the stomach, or if the experience of perceived stress creates a placebo effect in GERD patients.

Literature Review

In a study conducted by Nuñez-Rodriguez and Sivelo in 2008, participants were administered the SCL-90-R questionnaire, which measures psychosocial stress. Among these participants, a ratio of them suffered from GERD, and their results from the SCL-90-R confirmed their hypothesis that those suffering from GERD also suffer more from psychological conditions such as anxiety, depression, and higher levels of self-perceived stress (Nuñez-Rodriguez & Sivelo, 2008). Mizyed, Fass, and Fass (2009) stated in their study regarding sexual and physical abuse victims that not only are these two categories of individuals more likely to suffer from GERD than any other cohort of people, but those with a preexisting psychological disorder such as schizophrenia or major depression report suffering from GERD more than those without the existence of a psychological disorder. They discovered in their study that tricyclic antidepressants and benzodiazepines also play a large role in the development of gastroesophageal distress and heartburn (Mizyed, Fass, & Fass, 2009).

Poh, Hershcovici, Gasiorowska, Navarro-Rodriguez, Willis, Powers, Ashpole, Wendel, Noelck, and Fass (2011) discovered in their study regarding proton-pump inhibitor medication that not only does this type of medication help alter the esophageal mucosa, but it also helps alter the stimulus response functions of acid (Poh et al., 2011). Their study found that in times of acute stress, the perceptual sensitivity to GERD increases, but with a proton-pump inhibitor (such as Prilosec), this reaction decreases over time. Bradley, Richter, Pulliam, Haile, Scarinci, Schan, Dalton, and Salley (1993) sought answers regarding perception of GERD versus an actual episode of heartburn during times of anxiety and stress, and found that individuals higher in stress and anxiety tend to perceive mild cases of esophageal reaction as being painful reflux symptoms, (Bradley et al, 1993). Though dated, this study demonstrates the effect that the mind can have on influencing the body and our perception of pain and injury.

Discussion

There is little scientific evidence supporting the notion that some episodes of GERD are intensified and made worse by perception and expectation, creating a type of negative placebo effect (or in some cases one might say it is a self-fulfilling prophecy). Some scientists speculate that the amount of exercise and BMI relates to the presentation and development of GERD, but there is no evidence to support such claims, and recently the Body-Mass Index method has been discarded as a proper unit of measuring a person’s physical health condition. Those higher in psychological comorbidity with GERD are more likely to experience esophageal discomfort and heartburn, but there is not enough conclusive evidence to support body type having a relation to GERD.

Proton-pump inhibitor (PPI) medication such as Zantac and Prilosec help to reduce the burning effects of the acid and, as stated in the findings, their effects are also influenced by a patient’s susceptibility to stress and anxiety. Because the comorbidity related to stress and anxiety is so strong, most people diagnosed with GERD are recommended a diet change. For example: cigarettes, coffee, chocolate, and citrus fruits are all well-known triggers for acid reflux, and in those with GERD, can create regurgitation and heartburn. A person engaging too actively in any of those has a higher risk of developing GERD and making symptoms worse.

Dr. Jonathan Schreiber, a gastroenterologist at Mercy Medical Center in Baltimore recommends that those suffering from GERD and high levels of stress engage in physical exercise and use calming techniques such as meditation and yoga (Mann, 2009). Up until recently, the common prescription for esophagus-related issues came down to medications, but now doctors are becoming more patient-centered and recommend that patients engage in behaviors typically recognized in Eastern medicine, such as yoga, meditation, and mindfulness to help ease and eliminate their symptoms. They have begun treating GERD by first treating anxiety and trying to put the focus on stress instead of the disorder.

Summary and Conclusion

Gastroesophageal reflux disease is a medical disease believed to be related to the way the sphincter connecting the small intestine to the esophagus reacts, and how the esophagus is able to block acid and bile from regurgitating back into the esophageal lining. At an objective glance, the solution is to medicate instead of ask “why?,” but that is the most important question of the diagnosis. Although stress and anxiety are mostly only speculated in relation to GERD at this point in research, the connection is very clear. From personal experience, when participating in activities such as exercise, yoga, meditation, eating right, and practicing mindfulness, symptoms seem to lessen.

If stress is the link to GERD, and the attacks happen mostly at night, implementing a combination of a PPI with Eastern medicine could result in less GERD attacks at night, increasing the quality of sleep. Because of the gravitational pull of acid in the esophagus, laying down will intensify this symptom and can be so severe as to wake a person. The semi-solution is more pillows, but the actual solution could be as simple as stress management. Additionally, a change in diet proves to be extremely beneficial, especially where alcohol, tobacco, and caffeine are concerned. Because caffeine stimulates the central nervous system anyways, stressed out individuals suffering with GERD may experience not only acid from coffee (if that is the drink of choice), but also more acid from the release of stress hormones and a heart that is working faster than normal.

GERD is a proven medical condition that is the result of a malfunction occurring somewhere between the esophagus and small intestine, and though this is empirically supported through years of data, the stress and anxiety response is not. The placebo effect was mentioned earlier with regard to creating symptoms that may not ordinarily be there, and this is in connection to the patient’s response to acute stress. If a patient goes to be dreading or thinking about experiencing that twinging heartburn, they are more likely to experience it. Likewise, if they expect to experience symptoms when eating a certain food or experiencing stress in some way, they are more likely to actually have those symptoms. Of course the same effect potentially applies to PPIs in which a patient may believe the medication works, so they continue to take it. If they miss a dose, however, they will have immediate painful symptoms.

The best solution to easing the sufferings of GERD and creating a healthier lifestyle is to take part in mindfulness, in which one stays connected with the present moment and alleviates stresses from days passed and future, consume a diet lacking triggering foods, and use stress management coping techniques such as exercise, yoga, meditation, reading, and any other subjective calming activity a patient can use to stay connected positively to the present.

References

Bradley L. A., Richter J. E., Pulliam T. J., Haile J. M., Scarinci I. C., Schan C. A., Dalton C. B., & Salley A. N., (1993). The relationship between stress and symptoms of gastroesophageal reflux: the influence of psychological factors. The American Journal of Gastroenterology, 88(1), 9-11.

Mann, D., (2009). Feeling stressed? Why you may feel it in your gut. Home Remedies and Prevention. Retrieved from http://www.health.com/health/condition- article/0,,20279852_2,00.html

Mizyed, I. I., Fass, S. S., & Fass, R. R. (2009). Review article: gastro-oesophageal reflux disease and psychological comorbidity. Alimentary Pharmacology & Therapeutics, 29(4), 351- 358. DOI:10.1111/j.1365-2036.2008.03883.x

Nunez-Rodriguez, M .H., & Sivelo, R. M., (2008), Psychological factors in gastroesophageal reflux disease measured by SCL-90-R questionnaire. Digestive Diseases & Sciences, (53)3071-3075. DOI 10.1007/s10620-008-0276-0

Poh, C. H., Hershcovici, T. T., Gasiorowska, A. A., Navarro-Rodriguez, T. T., Willis, M. R., Powers, J. J., & ... Fass, R. R. (2011). The effect of antireflux treatment on patients with gastroesophageal reflux disease undergoing a mental arithmetic stressor. Neurogastroenterology & Motility, 23(11), e489-e496. doi:10.1111/j.1365- 2982.2011.01691.x