From butterflies in your stomach before giving a big speech at work to an ulcer that acts up whenever things get tough, our gastrointestinal health seems to be intimately connected to our emotions. Gastroesophageal reflux disease (GERD) or acid reflux is no exception, and heartburn symptoms can escalate right along with your workload.

However, the relationship between stress and heartburn is a tricky one; just as one man’s stress is another’s adrenalin rush, stress may sock in the gut some - but not all - people who have GERD.

And although stress may exacerbate GERD symptoms, it’s unlikely to be the underlying cause of your chronic heartburn. In the past, stress was thought to be the culprit in a variety of gastrointestinal problems, including ulcers and inflammatory bowel diseases such as Crohn’s disease. Now it’s known that bacterial infections (in the case of ulcers) and underlying inflammation (in bowel diseases) are to blame, not stress.

Stomach acid may rise, but not everyone feels the burn
Even if excess weight, smoking, alcohol, or other GERD-triggering factors are the underlying cause of your heartburn, stress can make you feel the symptoms of acid reflux more acutely.

“Stress can affect many gut functions, and we know that patients who are under a lot of psychological stress suffer from more severe reflux symptoms—without necessarily having more severe reflux,” says Mitchell Cappell, MD, PhD, the chief of gastroenterology at Beaumont Hospital in Royal Oak, Mich. “We live in stressful times and heartburn is incredibly common,” he says.

In surveys, the majority of people who experience acid reflux identify stress as a common trigger. The problem is that studies have failed to find a connection between the stress and the amount of stomach acid in the esophagus, which is the ultimate cause of heartburn pain. One explanation for this discrepancy is that stress may cause what’s known as “hypervigilance.” In other words, stressed people become more sensitive to and have a greater awareness of physical symptoms that may not bother them if they weren’t stressed.

In a 2005 study in the Journal of Psychosomatic Research, researchers measured the esophageal acid levels in more than 40 patients who had chronic heartburn and acid reflux. While the measurement was taking place, the researchers induced stress in half of the participants by requiring them to prepare and deliver a five-minute speech. The acid levels in both groups were nearly identical; patients in the “stressed” group, however, reported more intense acid reflux symptoms, suggesting that their sensitivity to their symptoms had been heightened.

Findings such as this don’t necessarily mean that stress-related reflux is “all in your head.” Some experts suggest that stress may excite areas of the brain that in turn make pain receptors in the esophagus more active. So acid levels may not rise that much more in stressed people than carefree ones, but each drop of acid may become that much more painful.

In addition, it’s known that people who are stressed can have a drop in levels of hormone-like substances known as prostaglandins, which can help coat the lining of the stomach and protect it from acid, says Jonathan Schreiber, MD, a gastroenterologist at Mercy Medical Center in Baltimore. “Once you are under stress, prostaglandin levels go down.” Certain drugs block the production of prostaglandins, including anti-inflammatory drugs such as ibuprofen and naproxen, which is why this common class of drug is often a cause of stomach problems, including nausea and ulcers.

The bottom line? “There is a strong connection between stress and acid reflux,” says Dr. Schreiber. No matter how the body and mind senses them, GERD symptoms are equally real.

Stress reduction is key
Reducing stress can ease heartburn and other gastrointestinal problems, but this is easier said than done, Dr. Schreiber says. “I often tell patients if I could write a prescription to relieve stress, I would write myself one first.”

There are, however, things that people can do to alleviate stress that may help lessen heartburn. For example, exercise is a great stress reducer. “This doesn’t mean running a marathon,” Dr. Schreiber says. “It could be walking for a half an hour a day. You really need to devote enough time to caring for yourself, whether reading a book, going for a walk, or doing yoga.” Creative pursuits such as writing, artwork, or music also play a role in stress reduction.

“It’s really different strokes for different folks,” Dr. Cappell says. “Do whatever it is that calms you. Sometimes it is as simple as listening to music.”

Talking to a therapist, clergy member, or even a good friend about your problems can also help mitigate stress, he says.

Healthy habits go a long way toward combating stress. It’s easy to resort to things that we know are not good for us, such as smoking and consuming alcohol or excessive caffeine, when times are tough.

And it’s no coincidence that these are some of the same things that doctors know increase our risk of heartburn. Caffeine, smoking, and alcohol may relax the lower esophageal sphincter, which is the muscle connecting the esophagus with the stomach, and allow acid easy access up the food pipe.

If you’re under stress, be extra careful to avoid known heartburn triggers such as chocolate, citrus fruits and juices, tomatoes and tomato sauces, spicy or fatty foods, full-fat dairy products, and peppermint. Other tips include trying to make mealtime as relaxing as possible, perhaps by playing some soothing music. Eating smaller meals also helps. Don’t lie down too soon after eating, and try to sleep with your head raised. The good news is that there are also many types of medications to help combat heartburn if none of these methods helps you feel better.

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Denise Mann