Digestive problems tell only part of the story of what it’s like to live with IBD (inflammatory bowel disease).
The IBDs (Crohn’s disease, ulcerative colitis, and indeterminate colitis) are incurable conditions that primarily target the digestive system. Some of the common signs and symptoms of IBD include diarrhea, weight loss, abdominal pain, and fevers.
IBD is strongly associated with stigma about “bathroom” disorders, which leaves patients isolated, often finding it challenging to discuss their health with others. Further, the signs and symptoms may keep people with IBD from participating in activities outside their homes and limit their ability to go to work and school.
The isolation can become profound and lead to a host of emotions, as well as contribute to depression and anxiety. (Bannaga, 2015) However, it’s still not common for people with IBD to be referred to a mental health professional for treatment.
Receiving treatment from a mental health professional can be an important part of a treatment plan for people with IBD. A small but growing specialty of psychologists, called gastropsychologists, has special training in treating patients with gastrointestinal diseases.
Anxiety and Depression in IBD
Anxiety and depression are not causes of IBD, but they are closely associated. The challenges of being diagnosed and living with these diseases, understandably, lead to the development of mental health challenges. The symptoms of anxiety and depression may then negatively affect the course of IBD. This is called a bidirectional effect. (Gracie, 2018)
One study used a clinical scale, called the Hospital Anxiety and Depression Scale (HADS), to determine the levels of anxiety and stress in 103 people living with ulcerative colitis and 101 people living with Crohn’s disease. The study also included 124 people who did not live with a form of IBD. What researchers found was that people with IBD had higher anxiety and depression scores on the HADS than the people in the healthy control group. (Goodhand, 2012)
Certain factors were different between people with ulcerative colitis and those with Crohn’s disease.
In ulcerative colitis:
- Anxiety was tied to perceived stress and a new diagnosis
- Depression was associated with stress, being in the hospital, and active disease
In Crohn’s disease:
- Anxiety was associated with perceived stress but also included abdominal pain and lower socioeconomic status
- Depression was associated with perceived stress and aging
What Is a Gastropsych?
A gastropsychologist (also called a GI psychologist or a gastropsych) is a clinical psychologist who specializes in health psychology. Health psychology training focuses on how physical health or illness affects mental health.
This includes several aspects of disease, including how it affects people psychologically, socially, and culturally. The primary focus of a health psychologist is supporting the mental health of people with physical conditions. A GI psychologist may help their patients with sleep issues, chronic pain, fatigue, and digestive-specific concerns such as disordered eating or dietary restrictions.
How A GI Psychologist Supports People with IBD
The brain and the digestive system communicate. This gut-brain axis can become disrupted and cause digestive problems. For those who live with IBD, digestive symptoms may cause psychological stress or anxiety, which in turn may lead to more symptoms. This can become a pattern that is difficult to break without outside intervention. Seeing a mental health professional for treatment may help, and a GI psychologist has special training in addressing the special concerns of people who live with digestive disease.
An initial consultation is often the first step in getting established with a GI psychologist. During the consultation, the psychologist can learn more about the issues that need to be addressed and determine if GI psychology will be helpful. Part of this consultation may include questions to learn more about symptoms and how they affect quality of life. It could also include some questionnaires to understand more about symptoms of anxiety, depression, or other mental health concerns.
At the start of therapy, the psychologist will put together a plan of action. The number of appointments suggested will differ from person to person. You may start with 6 to 8 appointments. This is because most of the work is skills-based and can be completed in that timeframe. If more sessions are needed, they’ll be added.
In some cases, people may return from time to time for additional sessions to address problems as they arise, such as a new diagnosis, worsening disease activity, or the need for surgery or other treatments.
Cognitive-Behavioral Therapy
One tool that psychologists use to help people with IBD is cognitive-behavioral therapy (CBT). CBT is a treatment for many conditions, including anxiety, depression, and other mental health issues. A psychologist and a patient work together to address problem areas and find solutions.
At the core of CBT is the reframing of thought patterns. This can include recognizing unhelpful thought patterns, working through them, and learning to redirect them to calm the mind. A therapist may further personalize CBT to address a client’s individual needs.
In IBD, CBT might be used in a variety of ways. One small study looked at using CBT to treat fatigue. Fatigue in IBD is common, yet not well understood, and there are few treatments available. This study of 10 people with IBD who completed all 8 CBT sessions showed improved quality of life for up to a year after the study ended. Researchers call for a larger pilot study and then, if there are benefits, a randomized controlled trial. [Artom, 2019]
Another study examined an IBD-specific form of CBT. Two groups of 59 patients with IBD received CBT, but one group received it right away, and the other group received CBT after a wait of 3 and a half months. Patients completed 5 or more CBT sessions to be included in the analysis. Researchers found that CBT affected both groups. Patients reported an improved quality of life (using the IBD Questionnaire), as well as decreased scores for depression and anxiety (using HADS). (Bennebroek, 2017)
One form of CBT studied in IBD is called acceptance and commitment therapy (ACT). In one study, 122 people with stable or mild IBD completed an 8-week ACT program or received usual care (not including ACT). Researchers saw the stress level and depression in the ACT group decrease when compared to the group that didn’t receive therapy. However, there wasn’t an effect on anxiety levels. (Wynne, 2019)
Gut-Directed Hypnotherapy
“Hypnotherapy” may bring up thoughts of hypnosis as a parlor trick. However, gut-directed hypnotherapy is an effective, evidence-based treatment methodology that can help people living with digestive disease. For some people, the nerve endings in their digestive system react more strongly to stimuli. This can lead to symptoms like abdominal pain, diarrhea, or constipation.
During gut-directed hypnotherapy, a licensed psychotherapist helps a patient relax and then address issues affecting digestion through guided imagery. This may occur over 7 to 10 weekly or bi-weekly sessions, each lasting 30 to 60 minutes. In between sessions, patients are often given audio to listen to or other homework that reinforces the skills from therapy sessions.
One study looked at gut-directed hypnotherapy in people with ulcerative colitis. One group underwent gut-directed hypnotherapy while another group received one-on-one talk therapy. The results showed that those who took part in gut-directed therapy went longer between flare-ups (approximately 2.5 months). The authors concluded that hypnotherapy is likely to benefit patients with mild-to-moderate ulcerative colitis, especially because most patients do not receive any mental health interventions. (Keefer, 2013)
Studies show that gut-directed hypnotherapy is also helpful for use in treating irritable bowel syndrome (IBS). While IBS is a different condition from IBD, it’s estimated that as many as 50% of people with IBD also live with IBS, and therefore might see a benefit from this treatment. Research shows the benefits of gut-directed hypnotherapy can last anywhere from 1 to 5 years in up to 83% of patients with IBS. (Ballou, 2017)
Finding a Therapist
Finding a therapist is challenging, especially when IBD and its associated problems take up so much time. However, finding a qualified therapist and having them join the IBD team can greatly improve both quality of life and disease activity. Patients can start by looking in several places for a therapist. First, ask the gastroenterologist’s office whether they have a relationship with a therapist and can make a referral. If that’s not an option, it’s possible to find a therapist by using the practitioner finders from a professional psychologist society:
- Association for Behavioral and Cognitive Therapies: http://www.findcbt.org/xFAT/
- American Board of Professional Psychology: https://abpp.org/Directory
- American Psychological Association Practice Organization: http://locator.apa.org/?_ga=1.3664691.2048346585.1491509681
- Rome Foundation Gastropsychologist Directory: https://romegipsych.org/
Some people may find that the first therapist they talk to is not the one with whom they continue and receive treatment. If possible, it may help to talk to a few different therapists to find the best fit. Most therapists will schedule an initial “get to know each other” session, usually at no cost, to determine if a good working relationship can be established. Mental health professionals know that not every therapist can work with every patient.
The Bottom Line
Studying the effects of psychological interventions is extremely difficult. One reason is there’s no way to use a placebo or to blind the patient or their physician to the intervention. Patients will know when they receive therapy, unlike with medical treatments where a “sugar pill” can be given and only the researchers would know who received that versus who received the medication being studied.
Further, psychogastroenterology is an emerging field. People who live with IBD may not be aware that there are professionals who specifically target the interplay between gut health and mental health. Some doctors may not know this either.
People often think therapy is long-term, but that’s not always the case. Meeting with a GI psychologist can be short-term, with occasional touchpoints in the future if needed. These therapies often have clear goals; it is not talk therapy that goes on indefinitely. People with IBD should have their mental health addressed, and seeing a gastropsychologist may be the best way to improve quality of life and ensure that stress and anxiety are managed.
Sources
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