How psychosocial factors affect the gut: Disorders of Gut-Brain Interaction



What are Disorders of Gut-Brain Interaction?


Disorders of gut-brain interaction are characterised by gastrointestinal symptoms associated with any combination of the following: abnormal intestinal contractions, increased sensitivity to pain within the internal organs, altered mucosal and immune function, altered gut microbiota, and altered central nervous system processing. The most common disorders of gut-brain interaction are Irritable Bowel Syndrome (IBS) and non-ulcer dyspepsia. There may be different reasons for developing such disorders, and psychological distress is one of them.


The Gut-Brain Connection


The brain and the gut are closely connected. They send messages to each other through nerves and chemical signals. The intestines communicate with the brain about their condition, while the brain directly regulates the activity in the stomach and intestines. When something disturbs the brain or the nervous system for a prolonged period, such as extreme psychological stress or negative emotions, poor sleep, or physical infections, gut-brain communication can become abnormal. When this occurs, the brain perceives sensations from the gut more intensely than is normal and may send signals that disturb the functioning of the gut.



Why Do I Have to See a Psychologist for a Stomach Issue?


Many people feel anxious or confused when their gastroenterologist makes a recommendation for them to see a psychologist. Oftentimes, there are misconceptions that a referral to a psychologist implies that their gastrointestinal symptoms are a result of a psychiatric disorder, “it’s all in their mind”, or that their doctor has given up on medical treatment. It is important for patients to understand that these are not true – these symptoms are real and psychological therapy augments and complements medical treatment.


There are several reasons why seeing a psychologist can help you:

  • Stressful life events can cause the worsening of gastrointestinal symptoms.

  • Traumatic events such as abuse are linked to higher chances of developing IBS and other disorders of gut-brain interaction.

  • Many patients with disorders of the gut-brain interaction also suffer from Generalized Anxiety Disorder (GAD) and Major Depressive Disorder (MDD). Moreover, these comorbid conditions are associated with poorer outcomes.

  • Due to the bi-directional communication pathways in the brain-gut axis, the brain strongly influences gastrointestinal sensations and functions. External stressors can affect gastrointestinal pain perception and functions, while gastrointestinal symptoms affect patients’ mood, stress levels, and pain perception.

  • In fact, because the brain helps to regulate the gut, it can often be used to reduce gastrointestinal symptoms regardless of whether it is causing the symptoms. Apart from medications that reduce the sensitivity of the brain to gastrointestinal sensations, this can be achieved through psychological therapy.

  • Psychological therapy has been recently included in the best practice update for the treatment of disorders of gut-brain interaction.


To put it briefly, psychosocial factors such as stress or one’s emotional response to stress may affect physiological functioning. While it is important to note that disorders of gut-brain interaction are also not psychiatric disorders, stress and psychological or emotional distress (such as depression and anxiety) can worsen your gastrointestinal symptoms. As such, there is a need for supplemental interventions that can help reduce symptoms and life impairment of patients who remain highly symptomatic in spite of all that usual medical care approaches can offer.


A psychologist can be someone who provides such supplemental treatments. Several modes of psychological therapies, including Cognitive Behavioural Therapy (CBT), relaxation training, and biofeedback, have been empirically tested. It was found that the use of these psychotherapies led to significant improvements in gastrointestinal symptoms, quality of life and emotional well-being.


How Does Treatment Work?


Diagnosis


According to the Rome Foundation, a non-profit organization that provides support for the diagnosis and treatment of disorders of gut-brain interaction, the disorders are mainly classified by symptoms instead of psychological criteria. Updated in 2016, the diagnostic criteria were further refined to allow for more targeted treatment. For instance, while different subtypes of IBS were once considered distinct disorders, the symptom presentations now exist on a spectrum to recognise their shared features.


The following are some advantages of classifying the disorders by symptoms:

  • Patients tend to visit gastroenterologists because they are experiencing symptoms.

  • Symptoms may not be easy to localise, especially in particularly painful disorders such as IBS and non-ulcer dyspepsia. In such cases, the classification of disorders into anatomic regions (oesophageal, gastroduodenal, bowel, biliary, and anorectal) may pose challenges.


Where Psychological Therapy Comes In


The Rome Foundation has highlighted that the most effective management of disorders of gut-brain interaction takes a biopsychosocial approach. This means that other than early life influences such as genetics and environment, as well as physiology, psychosocial factors should also be considered.


Psychological therapy effectively helps with stress, anxiety, depression, and longstanding and/or current traumatic experiences, which are commonly associated with gastrointestinal symptoms. Researchers are still examining possible causes of gut-brain dysfunction. In some cases, mood disorders develop after the patient has already experienced gastrointestinal symptoms, while in other cases the reverse is observed. According to Holtmann and colleagues (2018), even if the presence of a disorder of gut-brain interaction is identified using defined symptoms, it may have developed from different causes. This emphasises the need for supplemental interventions to try to identify a suitable treatment approach for each patient.


CBT is not a cure for disorders of gut-brain interactions. However, the tools and skills patients acquire during therapy can reduce the stress of coping with a chronic disorder. As stress levels decrease, symptoms often improve because of the reduced physical activation that can make symptoms worse. Through therapy, patients can learn to better manage their symptoms, make lifestyle changes, strengthen coping mechanisms and build resilience.


Depending on the patient’s background history and formulation (gathered during the initial assessment phase of treatment), the psychologist will first work with you to find out your therapy goals and collaboratively work out the most suitable psychological treatment plan that is individualized to you.


Who Can Benefit?


Patients who continue to have symptoms after 3-6 months of medical management and those whose care presentation suggest that stress or emotional symptoms are likely to be exacerbating gastrointestinal symptoms or causing impairments in coping with their illness can be provided psychological therapy.



Sources:


1. Chitkara, D.K., van Tilburg, M.A., Blois-Martin, N., & Whitehead, W.E. (2008). Early life risk factors that contribute to irritable bowel syndrome in adults: A systematic review. American Journal of Gastroenterology, 103(3),765-774. doi: 10.1111/j.1572-0241.2007.01722.x


2. Drossman, D.A. (1999). Do psychosocial factors define symptom severity and patient status in irritable bowel syndrome? The American Journal of Medicine, 107(5A), 41S-50S. doi: 10.1016/S0002-9343(99)00081-9


3. Drossman, D.A. (2016). Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV. Gastroenterology, 150(6), 1262-1279. doi: 10.1053/j.gastro.2016.02.032


4. Holtmann, G., Shah, A. & Morrison, M. (2018). Pathophysiology of Functional Gastrointestinal Disorders: A Holistic Overview. Digestive Diseases, 35, 5-13. doi: 10.1159/000485409


5. Keefer, L., Palsson, O.S., & Pandolfino, J.E. (2018). Best practice update: Incorporating psychogastroenterology into management of digestive disorders. Gastrenterology, 154(5), 1249-1257. doi: 10.1053/j.gastro.2018.01.045


6. Levy, R.L., Olden, K.W., Naliboff, B.D., Bradley, L.A., Francisconi, C., Drossman, D.A., & Creed, F. (2006). Psychosocial aspects of the functional gastrointestinal disorders. Gastroenterology, 130(5), 1447-1458. doi: 10.1053/j.gastro.2005.11.057


7. IrritableBowelSyndrome.net. (2016, December 13). New Rome IV Diagnostic Criteria for IBS. Retrieved July 13, 2020, from https://irritablebowelsyndrome.net/clinical/new-rome-iv-diagnostic-criteria/


8. Palsson, O.S. & Whitehead, W.E. (2013). Psychological treatments in functional gastrointestinal disorders: A primer for the gastroenterologist. Clinical Gastroenterology and Hepatology, 11(3), 208-216. doi: 10.1016/j.cgh.2012.10.031


9. Van Oudenhove, L., Vandenberghe, J., Vos, R., Holvoet, L., Demyttenaere, K., & Tack, J. (2011). Risk factors for impaired health – Related quality of life in functional dyspepsia. Aliment Pharmacology & Therapeutics, 33(2), 261-274. doi: 10.1111/j.1365-2036.2010.04510.x


10. Whitehead, W.E. (1996). Psychosocial aspect of functional gastrointestinal disorders. Gastroenterology Clinics of North America, 25(1), 21-34. doi: 10.1016/S0889-8553(05)70363-0


11. Whitehead, W.E., Palsson, O, & Jones, K.R. (2002). Systematic review of the comorbidity of irritable bowel syndrome with other disorders: What are the causes and implications? Gastroenterology, 122(4), 1140-1156. doi: 10.1053/gast.2002.32392



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