Gastrointestinal Diseases: Psycho-social Aspects

Antonina Mikocka-Walus, Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
Lesley Graff, Department of Clinical Health Psychology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
 2015 Elsevier Ltd. All rights reserved.

Abstract

An interconnection between psychological and gastrointestinal (GI) functioning has long been recognized, incorporating
multiple mechanisms and considering bidirectional processes. However, exciting discoveries regarding the role of stress and
depression in etiology and disease course have shed new light on the understanding of biopsychosocial processes in chronic
GI conditions. This article provides an introduction to GI tract functioning, GI disorders, and stress mechanisms in the gut,
followed by an overview and discussion of the psychosocial impact of these disorders, the role of stress and mental
comorbidity in GI disorders, and the current knowledge regarding psychological interventions for GI disorders.

Background approximately 90% of the body’s serotonin, supporting

Historically, a link between psychological and gastrointestinal
(GI) functioning has been well recognized. The term ‘nervous
diarrhea’ started appearing in medical texts in the mid-1800s.
In the early 1900s, physiologist Walter Cannon observed that
emotional calmness was important to normal digestion, and
speculated that mental distress may contribute to disturbed
digestion. For several decades in the twentieth century, there
was a predominant view that psychodynamic conflicts played
a central role in the cause of ulcerative colitis, an inflamma-
tory bowel disease (IBD), supported in part by Cecil Murray’s
published case reports in 1930. This link between psychology
and gut functions has worked its way into folk wisdom and
common language, with expressions such as “that took a lot of
guts” and “butterflies in the stomach.” The contemporary
understanding of the interplay between psychological func-
tioning and GI disease is much more complex, incorporating
multiple mechanisms and considering bidirectional
processes.
The next sections provide an introduction to GI tract func-
tioning, GI disorders, and stress mechanisms in the gut, fol-
lowed by an overview and discussion of the psychosocial
impact of these disorders, the role of stress and mental
comorbidity in GI disorders, and the current knowledge
regarding psychological interventions for GI disorders.
The GI Tract and the Brain–Gut Axis
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the view of a highly developed brain–gut communication
pathway. The GI tract is regulated through its own internal
nervous system, the enteric nervous system, and the central
nervous system, via a complex interaction of the neuro–
endocrine–immune systems, with the autonomic nervous
system playing a central role in brain–gut communication
(Bonaz and Bernstein, 2013).
This bidirectional connection system is known as the brain–
gut axis. While gut action typically occurs without much
awareness or focus, visceral afferent information from the GI
tract has been shown to be more available to conscious
awareness than other body systems (e.g., cardiovascular).
Actions including gastric emptying, transit time, and small and
large intestine contractions can be altered by psychological
processes such as emotion and stress (Mayer et al., 2001).
Certainly, gut upset (e.g., loose stool, nausea) is a common
experience for many when stressed.
Organic and Functional GI Disorders
Many of the disorders of the GI tract are attributed to motor or
sensory disturbances. The GI disorders are typically categorized
as organic or functional; the organic disorders are those defined
by structural or inflammatory abnormalities, and the func-
tional disorders reflect chronic or recurrent GI symptoms in the
absence of these abnormalities, suggesting a problem in the
functioning of the gut. While the functional disorders are not

typically associated with greater health morbidity or mortality,

The human GI tract extends from the mouth to the anus, and
includes the esophagus, stomach, approximately 13 feet of
small intestine, and 7 feet of large intestine. The GI tract has
a crucial role in survival, as it is responsible for breaking down
food, extracting nutrients, exchanging fluids, and expelling
waste. It is a dynamic organ that actively moves contents
through the tract using coordinated ripple-type muscle
contractions. A microworld of bacteria, known as the gut flora
or gut microbiota, exists throughout the GI tract, and facilitates
the breakdown and processing of foodstuffs. This is the most
highly innervated organ in the body, and has the largest
concentration of neurotransmitters outside the brain, including
the organic disorders can be. Regardless, both types of GI
disorders result in significantly poorer quality of life even
compared to those with other chronic diseases, affecting social,
personal, and work domains of functioning.
Organic GI disorders include the acid peptic diseases (e.g.,
gastroesophageal reflux disease) and IBD. IBD is characterized
by recurring inflammation in the GI tract leading to abdominal
pain, bloody diarrhea, and fatigue. IBD has been increasing in
prevalence in recent decades, with current estimates as high as
500 per 100 000. The peak incidence is in young adulthood
(second and third decades); however, 25% of new cases are
diagnosed in children and adolescents. While IBD is clearly less

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 606 Gastrointestinal Diseases: Psycho-social Aspects

common than its functional counterpart, irritable bowel

syndrome (IBS), it can be difficult to achieve and maintain
remission for this condition, and it often requires costly
medication and surgery for disease management. Although
rare, it can also be associated with mortality. The pathogenesis
of IBD is thought to involve an exaggerated immune response
to normal microbes in the intestine, triggered by environ-
mental factors in those with a genetic susceptibility.
Functional disorders are generally more prevalent than
organic, with IBS the most common type. IBS is a chronic
relapsing condition involving bowel habit disturbance and
lower abdominal pain or discomfort. It affects approximately
10–20% of the adult population, has peak onset in the 30s and
40s, and is one of the 10 most common reasons to visit the
primary care physician. Nonulcer dyspepsia, with an estimated
prevalence of 12–15%, is an upper gut disorder with symptoms
of pain, bloating, and nausea; the symptoms are similar to
those of an ulcer, but investigation (upper endoscopy) does not
show an ulcer to be present. It is thought that these
conditions arise because of sensory nerve disturbances along
the brain–gut axis.

Stress and GI Disorders

While many of the GI disorders have differing etiologies, clin-

ical and experimental research suggests that stress may be
a common risk factor affecting disease course, and comorbid
psychological disturbances may be higher for those with GI
disease than the base rate in the community, as detailed in the
next sections. It is thought that the special link between the
brain and gut, and in particular, disruptions in communication
along the brain–gut axis, may help to explain these associations
(Bonaz and Bernstein, 2013). Altered gut motility and visceral
sensitivity have been seen as fundamental processes in the
modern understanding of functional GI disorders. Regions in
the brain that regulate emotional and cognitive functions,
including the amygdala, hippocampus, and prefrontal
cortex, are also involved in modulating gut function (Mayer
et al., 2001).
Experimental research suggests that stress can prompt
a range of GI tract disturbances such as increased intestinal
permeability, mucosal inflammation, and gastric ulcers (Caso
et al., 2008). At cell level, mucosal mast cells, and at endo-
crine level, corticotrophin-releasing factor have a central role in
immune system changes and inflammation of the mucosa. The
autonomic nervous system is highly sensitive to emotional and
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Figure 1 Psychoneuroimmunological pathways in inflammatory bowel
disease. Stress, via the limbic system, stimulates the HPA (a) and the
ANS (b) leading to the production of CRF, ACTH, and then cortisol and
the catecholamines. Noradrenaline is also released directly into the gut
mucosa from sympathetic nerve endings of the ENS (c). In addition,
mast cells lying close to enteric nerve endings degranulate releasing
tryptase, histamine, and other mediators (d). These neuromediators
through incompletely characterized mechanisms, including activation of
lymphocytes, stimulate epithelial chloride secretion and mucus produc-
tion, increase paracellullar and transcellular epithelial permeability.
Subsequent ingress of luminal bacteria into the mucosa triggers further
immune and inflammatory events involving dendritic cells, macro-
phages, and other cell types. ACTH: adrenocorticotropic hormone; ANS:
autonomic nervous system; CRF: corticotrophin releasing factor; ENS:
enteric nervous system; HPA: hypothalamic–pituitary–adrenal axis.
Originally published by Wahed, M., Rampton, D., 2013. Psychological
stress and related mood disorders, and their therapeutic implications in
IBD. IBD Monitor 13, 143–153. Reproduced with permission from
Remedica Medical Education and Publishing.

evaluative input (e.g., the ‘fight or flight response’). Recent

work suggests that there may be autonomic dysfunction in
individuals with organic or functional GI disorders, although
the specific nature of the sympathovagal balance, including
parasympathetic hyporeactivity, may be different among
disease types (Pellissier et al., 2010). Finally, the gut micro-
biome is just beginning to be explored as another pathway
through which psychological processes such as mood disorders
may interact with gut function. Converging research is sug-
gesting that intestinal microbes might be involved centrally in
modulating behavior and brain chemistry, and that environ-
mental influences such as stress can affect the microbial balance
in the gut (Bercik et al., 2012) (Figure 1).
Psychosocial Impact of GI Disorders
Health-Related Quality of Life
Health-related quality of life (HRQOL) in patients with chronic
conditions encompasses the effects of these conditions and
associated treatment on physical and psychosocial functioning
of the person living with the illness. HRQOL frequently has
been found to be impaired in those with chronic GI disorders.
For example, a systematic review concluded that HRQOL is
significantly reduced in patients with moderate-to-severe IBS, at
a level comparable to other chronic disorders such as depres-
sion (El-Serag et al., 2002).

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In organic GI conditions such as IBD, impaired HRQOL
may result from its incurability, unpredictability, and severity
of symptoms, surgery, and medication side effects, although
psychosocial factors may also play a role. A meta-analysis
found that disease-related factors only accounted for 37% of
the variance in HRQOL (van der Have et al., 2014). The authors
concluded that other variables such as illness perception,
sociodemographic factors, and mental health are also
contributory, and addressing those which are modifiable could
improve the HRQOL. In the functional disorders, diminished
HRQOL is attributed to disease-related factors including
unclear diagnosis and unavailability of universal treatment,
combined with debilitating symptoms and avoidance of
potential symptom triggers.
When HRQOL was directly compared between patients
with organic and functional GI conditions in a large (n ¼ 4441)
population-based study exploring self-perceived health status,
IBD participants reported poorer physical health, and IBS
participants reported poorer mental health and greater levels of
stress (Tang et al., 2008), demonstrating the interrelatedness of
somatic and psychosocial influences on HRQOL. In many
chronic conditions, including GI disorders, disability and
poorer HRQOL can be more strongly associated with under-
lying mental illness or psychological distress than the disease
per se, perhaps as depression and/or comorbid anxiety can
aggravate disease activity and negatively impact on disease
management.
HRQOL can be compromised for young people with IBD as
well (Greenley et al., 2010), as the impact of the disease and
treatment is evident in the overall development, with common
short stature and delayed puberty contributing to a visible
difference from peers. Pediatric patients with IBS also report
poorer HRQOL compared to healthy peers, although the
impact of their disease on time missed from school is not as
high as those with organic GI conditions (Varni et al., 2006).
For both pediatric IBD and IBS patients, poorer HRQOL is
often found to be related to embarrassment resulting from
frequent use of toilets and not rarely becoming a target of the
‘bathroom humor’ by the peer group.
Coping
Coping with chronic illness involves managing demands
imposed by the illness. These can include physical and mental
symptoms, as well as psychological adjustment to changes in
the functioning of the body and the social impact of illness on
one’s roles within the family and society. Comparing the
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coping approaches between patients with organic and func-
tional GI disorders, studies disagree on whether IBD and IBS
patients differ in their preferred coping strategies. While IBS
patients have been found to catastrophize more often than
IBD patients in some studies, other research does not
demonstrate such interdisease differences, showing that both
those with IBD and IBS differ from healthy controls, in that
the former tend to rely on passive coping approaches. A
comprehensive systematic review found that emotion-focused
coping was associated with worse psychological outcomes,
while the effect of problem-focused coping was, to some
extent, associated with better psychological outcomes in IBD
(McCombie et al., 2013).
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Gastrointestinal Diseases: Psycho-social Aspects 607
There is a dearth of data with respect to pediatric and
adolescent populations’ coping with the disease, with only
anecdotal reports of less well-developed coping skills than in
the healthy counterparts.
Social Support
Social support involves positive assistance (actual and
perceived) from a network of friends, family, and others. High
perceived social support has been linked with good health
outcomes; this is thought to relate to the practical assistance as
well as the emotional support that caring individuals can
provide. In patients with chronic GI disorders, social support
has not had much research attention. Available studies suggest
that those with IBD generally feel well-supported, although this
may not be the case for individuals with moderate-to-severe
functional symptoms. IBD patients reported more tangible,
affective, or emotional support and were more likely to have
experienced a positive social interaction compared to their
community non-IBD counterparts (n ¼ 388) (Rogala et al.,
2008). A beneficial effect of social support on disease course
has also been reported, with higher social support shown to
decrease the likelihood of disease deterioration in IBD (Camara
et al., 2011). For IBS patients, stress arising from conflict-laden
relationships is reported to be a stronger predictor of IBS
outcomes than the benefits arising from positive social support
in some studies, suggesting a detrimental effect of poor quality
support. Online social support groups, a relatively recent
phenomenon, are increasingly being reported as important
tools in providing social support for patients with GI condi-
tions (Malik and Coulson, 2011).
Social Functioning and Stigma
People with chronic GI disorders frequently report challenges
in social functioning. Preoccupation with toilet availability,
and symptoms such as diarrhea, bloating, and gas can make
social interactions difficult and may lead to isolation. Stigma
associated with bowel function can prevent those affected by
IBD and IBS from sharing the information about the diagnosis
or their needs regarding symptom management. The nature of
GI symptoms, the shame around potential loss of control, and
the anatomy focus on the bowel and rectum are taboo in many
cultures. Social gatherings often include or revolve around
food, which can be an obstacle for those with chronic GI
disorders due to self-imposed diet restrictions and avoidance of
restaurants resulting from fear of problematic ingredients.
Individuals who avoid certain social or professional situations
(e.g., visit to a theater or a business trip) may have their actions
misunderstood and interpreted as evidence of their lack of
dedication or negligence, rather than as a consequence of their
illness.
According to the largest study to date (n ¼ 269 IBS; n ¼ 227
IBD), IBS patients feel more stigmatized than their IBD coun-
terparts, which may be explained by the perception of IBS as
being a less ‘real’ disease given lack of pathological changes to
the bowel and lack of effective medical treatment (Taft et al.,
2011). Despite this, perception of stigma is more highly
correlated with poorer patient outcomes in IBD than IBS.
Having a GI disorder can adversely affect employability,
 608 Gastrointestinal Diseases: Psycho-social Aspects
particularly for those with more severe illness or difficulty
settling symptoms, resulting in loss of income, fewer career
prospects, or unemployment.
Social functioning is also reported to be impaired in young
people living with GI conditions. While parents report that
their adolescents with IBD function comparably to healthy
youth, the adolescents report the opposite; namely that their
social functioning is poorer than their healthy counterparts and
similar to that of other chronically ill young people (Greenley
et al., 2010).
Self-Image and Sexuality
People living with GI disorders, particularly disorders that
affect bowel habit, frequently report perceptions of being
‘unclean’ and concerns about managing bodily odors. While
there can be problems maintaining hygiene due to fecal
leakage, or in the case of IBD, as a consequence of colectomy,
often the perception is only subjective and results from the
belief that having a bowel problem makes a person ‘unclean.’
Disease-affected body image and self-esteem concerns can
fluctuate depending on disease status and life stage. In an
Australian study of middle-aged IBD patients (n ¼ 347
patients), 67% reported negative body image related to their
disease, with both men and women endorsing this self-view
(Muller et al., 2010). In addition, women and those who had
had bowel surgery were more likely to report decreased
frequency of sexual activity and decreased libido. While early
studies of self-esteem in young people with IBD suggested that
low self-esteem and distorted self-image were common,
a recent meta-analysis found no difference in self-esteem levels
between IBD patients, healthy controls, and young people with
other chronic conditions (Greenley et al., 2010). No similar
studies have been identified for functional adolescent or
pediatric populations.
In functional GI disorders, and IBS in particular, the
majority of studies on sexuality focus on childhood adversity
and trauma. When this was first examined, patients with IBS
were reported to have very high rates of childhood abuse,
including sexual abuse (up to 50%), at a prevalence that was
significantly greater than healthy controls. However, these
findings have been reexamined and the base rates of childhood
abuse in the general population have now been found to be
high, so there is some controversy about whether IBS is
uniquely associated with sexual abuse. In nonulcer dyspepsia,
a higher rate of physical and emotional abuse has been
observed when compared with healthy controls; however, very
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few studies have explored this issue.
Mental Comorbidity
Like other chronic health conditions, GI disorders have been
associated with high levels of perceived stress and greater
prevalence of mental disorders (e.g., anxiety and depression) as
compared to the healthy populations. These psychological
difficulties may result from disease burden, but may also be
a consequence of common pathways related to dysfunction
in the brain–gut axis and interconnection of neuro–
endocrine–immune systems as discussed above. Despite
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some similarities, depression, anxiety, and stress may play
a somewhat different role in etiology and disease progression
in organic and functional disease and are thus discussed
separately.
Depression, Anxiety, and Stress in IBD
Population-based studies have documented a higher lifetime
prevalence of depression in IBD compared to the community,
with estimated rates of 27 versus 12% (Walker et al., 2008). In
pediatric and adolescent IBD populations, prevalence of
depression was also found to be higher than for youth with
other chronic illnesses (Greenley et al., 2010). There is more
uncertainty about a higher prevalence of anxiety disorders in
IBD patients. While studies have reported higher levels of
anxiety symptoms for IBD patients, lifetime prevalence of
anxiety disorders was not found to be greater than for matched
controls in a population-based study; panic disorder showed
a trend for higher rates (8 vs 4.7%), and social anxiety rates
were significantly lower in IBD than controls (6 vs 11%)
(Walker et al., 2008). Comparisons of rates with other national
samples suggest that IBD patients may have higher rates of
panic, generalized anxiety, and obsessive–compulsive
disorders.
Anxiety and depression have been understood to be disease
sequelae, with impact on disease course rather than causal
factors for onset. However, studies have found that depression
predated the onset of IBD in many cases, and new experimental
work with animal models has demonstrated that inducing
depression increases susceptibility to spontaneous intestinal
inflammation in mice, raising the possibility of depression as
a potential etiological risk factor. With regard to disease course,
a review of 11 longitudinal studies of depression in IBD
concluded that it negatively impacts IBD course, with effects
such as a shorter time to relapse (Rampton, 2009).
There is a growing recognition of the role of stress in IBD
disease course, independent of mental disorders. A review of
nine longitudinal studies of stress identified a relationship with
increased inflammation and IBD symptoms (Maunder and
Levenstein, 2008), and recent prospective work confirmed
higher stress levels in the periods preceding symptomatic
disease flare (Bernstein et al., 2010). In addition, studies in
animal models have demonstrated that stress can induce colitis
and treating the animal with antidepressants restores vagal
function and reduces the intestinal inflammation.
Regarding the role of personality factors in IBD, studies have
examined personality traits such as neuroticism, perfectionism,
and alexithymia and found them to be more common in IBD
patients than their healthy counterparts. However, none of
these studies have prospectively evaluated personality prior to
disease onset, and these traits can be affected by current
emotional state.
Depression, Anxiety, and Stress in Functional GI Disorders
While high rates of mental comorbidity, ranging from 40 to
over 90%, have been reported for IBS patients presenting to
tertiary care centers (Drossman et al., 2002), population-based
studies have clarified that the majority of individuals with IBS
do not seek medical care, and are similar to non-IBS

individuals with respect to their mental health. Those with
moderate-to-severe GI symptoms tend to exhibit higher rates of
anxiety and depression, but it cannot be said with certainty
whether anxiety and depression precede or follow the GI
symptoms. In contrast, individuals with nonulcer dyspepsia,
who do not seek medical care, have been found to have poorer
scores on psychological domains than healthy controls, sug-
gesting that psychological morbidity might not be associated
with health care–seeking behavior of this group (Van
Oudenhove and Aziz, 2013).
Few studies have examined mental health in pediatric or
adolescent functional GI patients, so rates of comorbid anxiety
and depression in this population are largely unknown. There
is currently some evidence that patients with recurrent
abdominal pain in childhood have an increased risk of IBS
during adolescence and young adulthood, and thus possibly
a similar likelihood of developing a mental comorbidity at any
stage of their life.
The bidirectional relationship between anxiety, depression,
and functional GI conditions is well illustrated by the largest
longitudinal population-based study to date (Koloski et al.,
2012). Individuals with higher levels of anxiety or depression
at baseline were more likely to develop IBS, and baseline
depression was predictive of subsequent dyspepsia by the
12-year follow-up. Among individuals without elevated levels
of anxiety and depression at baseline, those with a functional
GI condition at baseline had significantly higher levels of
anxiety and depression at follow-up.
Stress is currently viewed as a risk or triggering factor for the
onset of IBS and nonulcer dyspepsia, with studies showing
higher levels of stress in the months preceding onset. Stress has
also been established as a contributor to ongoing symptoms
(Drossman et al., 2002). In fact, individual stress-sensitivity
appears to be a key factor in the severity and persistence of
functional GI symptoms. People reporting these gut symptoms
have been found to exhibit exaggerated motor and sensory
responses to stressors, including visceral hypersensitivity.
Similar to the research findings in IBD, very few studies have
explored personality traits in patients with functional GI
conditions. The available ones reviewed by Romanian
researchers (Surdea-Blaga et al., 2012) have found higher levels
of neuroticism for patients with nonulcer dyspepsia and IBS,
compared to healthy controls, with some also reporting higher
levels of conscientiousness and alexithymia in IBS. The IBS
patients were also found to have higher neuroticism levels than
IBD patients. However, it should be noted that neuroticism is
a trait which is very susceptible to state influences and has been
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commonly reported as elevated in many chronic conditions;
thus it is unclear whether it should be considered a precursor or
a consequence of the chronic illness.
Psychological Therapies in GI Disorders
The close relationship between the brain and the gut via the
brain–gut axis, the high prevalence of mental comorbidity in
GI disease, and the evident impact of psychological processes
on GI symptoms, disease course, and overall quality of life all
support that psychological health should be a clinical consid-
eration in GI disease management. Psychological therapies
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Gastrointestinal Diseases: Psycho-social Aspects 609
have been used as part of the treatment approach for several of
the GI diseases. These psychosocial interventions have been
more extensively examined in the functional illnesses such as
IBS and nonulcer dyspepsia, but the efficacy of various therapy
approaches has also been investigated in IBD. Psychotherapy,
and in particular, cognitive behavioral therapy (CBT), a type of
psychological therapy that uses an active, time-limited, and
structured approach, has been well-established as an effective
treatment for depression and anxiety, and in that regard it can
be an appropriate intervention for mental disorders in GI
patients. However, psychological therapies also aim to enhance
coping, decrease stress reactivity, and address problematic
behaviors (e.g., medication nonadherence, poor health habits),
which in turn may have a positive impact on GI disease
outcomes. While psychological therapies can affect GI and
immune functioning, there is some question about whether
they directly improve GI symptoms and disease course,
depending on which GI illness is being reviewed.
There has been growing interest in the efficacy of psycho-
logical interventions for organic GI disorders, in part because of
the positive results for functional GI disorders (described
below). Interventions that have been evaluated for IBD using
randomized controlled trials have included stress manage-
ment, CBT, psychodynamic therapy, and most recently,
hypnotherapy, with outcomes relating to psychological func-
tioning and impact on IBD symptoms and course. There have
been several systematic reviews, with mixed conclusions, in
part related to differing decisions on inclusion criteria and
study groupings. Most reviews included any psychotherapy-
type intervention, rather than considering only psychological
therapies with empirical support for efficacy in the general
psychotherapy literature. One meta-analysis of psychological
interventions in IBD (Timmer et al., 2011) concluded that there
was no significant impact on emotional problems or disease
activity. However, this review pooled theoretically different
approaches with potentially differing efficacy, thus decreasing
the likelihood of demonstrating an effect.
Overall, there is some consensus that the empirically sup-
ported treatments such as CBT and stress management (based
on CBT strategies) have more consistently demonstrated
improvements in HRQOL for IBD patients as well as in the
targeted comorbid depression and anxiety (Knowles et al.,
2013). In contrast, there have been few positive findings of
impact directly on IBD outcomes, although many studies
included only patients in remission, contributing to potential
floor effects. One well-designed large case–control study found
decreased medication use, decreased physician visits, and fewer
disease relapses following psychological treatment (Wahed
et al., 2010). Also treatment studies using hypnotherapy re-
ported reduction in IBD symptom severity. The hypnotherapy
results should be considered promising but preliminary, given
that they were based on a small number of patients who
received treatment. Methodological issues need to be more
systematically addressed to better ascertain efficacy for the
disease outcomes in particular.
The research on psychotherapeutic interventions for func-
tional GI disorders has significantly expanded over the last
decade. Studies have evaluated multiple therapy modalities,
including brief psychodynamic therapy, hypnotherapy, relax-
ation training, and CBT. Psychological treatments, as a class of
 610 Gastrointestinal Diseases: Psycho-social Aspects
interventions, have been found to be effective in reducing
symptoms in IBS, compared to pooled outcomes for controls
(Lackner et al., 2004). CBT has been shown to have a direct
effect on IBS symptoms independent of its effects on psycho-
logical distress. A systematic review and meta-analysis of IBS
outcomes and psychological therapies, which accessed data for
almost 1300 adult patients in randomized controlled trials,
also concluded that psychological therapies were effective for
IBS (numbers needed to treat ¼ 4; Ford et al., 2009). A similar
review of pediatric studies reached a parallel conclusion,
describing that psychological interventions with multiple
therapy components (e.g., relaxation, psycho-education,
cognitive therapy) were superior to standard care for
outcomes of pain and functioning (Brent et al., 2009). While
much of the research has focused on IBS, psychotherapy studies
assessing outcomes for nonulcer dyspepsia have almost
uniformly reported significant improvements in symptoms
posttreatment, and benefits have been found to last up to
1 year (Soo et al., 2005).
All these reviews acknowledge study limitations, which
qualify the strength of the conclusions, reflecting common
challenges in many psychotherapy studies such as small sample
size and difficulty blinding to treatment allocation. Neverthe-
less, treatment guidelines for IBS include psychological thera-
pies as recommended interventions, particularly emphasizing
CBT, psychodynamic interpersonal therapy, and hypnosis.
New directions for psychological intervention with IBS have
explored interoceptive exposure to gut sensations, mindful-
ness, and minimal contact treatments such as Internet delivery
of CBT interventions, with promising results.
Studies that directly compared behavioral therapies with
antidepressant medication for functional disorders (Drossman
et al., 2003) have reported a better response to the psycho-
logical interventions and lower dropout rates, the latter sug-
gesting a greater tolerance for the psychological versus
pharmacological therapy. Psychotherapy was also found to
result in significantly lower health care costs than medication
or usual treatment approaches, highlighting an important cost-
offset of psychotherapy.
Many, but certainly not all, patients are receptive to
psychological care as part of the GI disease management plan.
Inclusion of a psychological therapy can depend on availability
of the treatment, and is often recommended depending on
symptom severity, evident maladaptive coping, patient aware-
ness of a stress–symptom connection, and patient readiness to
engage in this type of treatment. While GI specialty clinics in
many countries have adopted a biopsychosocial approach in
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their disease management, this approach is not yet a standard
or common practice.
Conclusion
The interconnection of psychological and GI functioning is
evident in both organic and functional GI disorders, support-
ing the applicability of a biopsychosocial model for these
chronic conditions. The relationship seems to be bidirectional,
with each able to affect the other, although the etiological role
of psychological distress in GI disease such as IBD remains to
be elucidated. The findings from both animal and human
International Encyclopedia of the Social and Behavioral Sciences, Elsevier, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/universidadviu/detail.action?docID=1963260.
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studies in this area have contributed to new understandings of
biological underpinnings in psychological processes. These
interrelationships have opened up further directions for treat-
ment of GI disorders, with positive findings from psychological
interventions related to improvement of patient outcomes
and reduction of health care utilization. Nevertheless, more
rigorous treatment studies are needed to determine patients
most apt to benefit, efficient modalities for treatment delivery,
and protective effects for disease course. Continued research
efforts regarding the role of stress and preexisting depression,
particularly in inflammatory disease, are likely to increase the
understanding of the mechanisms linking the psyche and GI
disease, and perhaps will facilitate more widespread integra-
tion of biopsychosocial treatment in gastroenterology.
See also: Anxiety and Anxiety Disorders; Behavioral Medicine;
Chronic Illness, Psychosocial Coping with; Co-morbidity of
Mental and Physical Conditions; Depression; Evidence-Based
Medicine; Health Outcomes, Assessment of; Health Psychology;
Interoception; Mental Disorders, Epidemiology of; Mindfulness;
Personality and Health; Psychological Treatment, Effectiveness
of; Psychological Treatments: Randomized Controlled Trials;
Psychoneuroimmunology; Psychosomatic Medicine; Stigma,
Social Psychology of; Stress, Coping and Health.
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Relevant Websites
www.ibsclinic.org.au – IBSclinic.org
www.IBDclinic.org – IBDclinic.org
http://www.ibdmanitoba.org/ – IBD Clinical and Research Centre, University of Manitoba.
http://www.romecriteria.org/ – Rome Foundation