PSYCHOLOGICAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS

GASTROINTESTINAL DISORDERS AND SYSTEMIC DISEASE. PART I1

0889-8553/98 $8.00

+ .OO

PSYCHOLOGICAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS Comments M. Rodwan Hiba, MD, and Richard W. McCallum, MD

The traditional medical understanding of the word disease in Western civilization is that it refers to symptoms that can be explained by structural or biochemical abn0rma1ities.l~Patients do not always agree with this, however. Their definition probably is the presence of one or a combination of symptoms they consider abnormal. This definition of disease leads to identification of groups of patients with disturbing symptoms that are not accompanied by structural or biochemical abnormalities. These patients are often labeled as having functional syndromes. Gastroenterologists see a substantial number of these patients, with one study indicating up to 40% of the patients in gastrointestinal practices are patients with functional gastrointestinal disorders.u Another survey of 400,000 households in the United States in 1990 showed that two thirds of the population has one or more functional gastrointestinal symptoms, but most individuals would not seek medical attention. Symptoms that most often cause patients to seek medical consultation include pain and incontinence. More individuals with syndromes such as functional chest pain, functional dyspepsia, irritable bowel syndrome, chronic functional abdominal pain, and functional biliary pain may not

From the Department of Medicine, Division of Gastroenterology and Hepatology, Kansas University Medical Center, Kansas City, Kansas

GASTROENTEROLOGY CLlNICS OF NORTH AMERICA

-

VOLUME 27 * NUMBER 4 DECEMBER 1998

893

894

HIBA & McCALLUM

seek formal medical intervention. For a reason not well understood, functional constipation, functional dyspepsia, irritable bowel syndrome, and functional biliary pain occur more commonly in women. The frequency of health care-seeking behavior for functional gastrointestinal symptoms decreases with age and increases among lower-income groups. The presence of functional gastrointestinal disorders (Table 1) is associated with more physician visits for nongastrointestinal diagnose~.'~ The simultaneous interaction between different systems resulting in illness or disease needs to be understood. Illness is best understood in terms of a multifactorial model of causation, which assumes a complex interplay of biologic, psychological, and sociological variables. This interplay means that a given individual may have multiple interrelated systems at the cellular, tissue, organism, interpersonal, and environmental levels. This interaction between different systems is illustrated in Figure 1.

Table 1. FUNCTIONAL GASTROINTESTINAL DISORDERS Esophageal disorders Globus Rumination syndrome Noncardiac chest pain Functional heartburn Functional dysphagia Unspecified functional esophageal disorder Gastroduodenal disorders Functional dyspepsia Ulcerlike dyspepsia Dysmotility-like dyspepsia Unspecified dyspepsia Aerophagia Bowel disorders Irritable bowel syndrome Functional abdominal bloating Functional constipation Functional diarrhea Unspecified functional bowel disorder Functional abdominal pain Functional abdominal pain syndrome Unspecified functional abdominal pain Biliary disorders Gallbladder dysfunction Sphincter of Oddi dsfunction Anorectal disorders Functional incontinence Functional anorectal pain Levator ani syndrome Proctalgia fugax Dyschezia Pelvic floor dyssynergia Internal anal sphincter dysfunction Unspecified functional anorectal disorder

PSYCHOLOGICAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS

ACTIVITY

895

STATUS

Figure 1. Multiple factors that interplay to cause disease.

INTERACTION OF BIOLOGIC AND PSYCHOSOCIAL FACTORS IN GASTROINTESTINAL ILLNESS

Since 1910, when Pavlov performed his famous experiment, it has been well known and well documented in the literature that psychological stimuli affect the physiology of the gastrointestinal system. Techniques measuring psychophysiologic and psychosocial effects, however, such as ambulatory monitoring and health-related quality-of-life assessment, have only recently emerged.6,19, 23 Psychophysiologic Factors

Healthy individuals often report the presence of noxious gastrointestinal symptoms as a reaction to stress.ll Disturbance in bowel function, in turn, can affect emotional centers in the brain.3 Patients with gastroesophageal reflux disease reported worsening of their symptoms with stress, although an esophageal pH probe did not confirm any change in the degree of the acid re flu^.^ Brain-Gut Interactions

Experimental designs support the presence of a bidirectional relationship between gut and brain. Functional gastrointestinal disorders can be explained by a hypothesis that they result from dysregulation of neuroenteric systems. Patients with gastrointestinal functional disorders have increased motor reactivity to various stressors, such as food, balloon distention, various hormones, or physical and psychological stressors. This reactivity varies among individuals and within the same individual and can be modified by central nervous system input; motility

896

HIBA & McCALLUM

disturbances in irritable bowel syndrome, for example, are absent during sleep. This reactivity would help explain how traumatic psychosocial experiences (physical or sexual abuse) can produce worse symptoms and greater illness behavior in patients with functional disorders when compared with patients with structural abnormalities involving the same organ system(s). It was concluded that visceral afferent fibers project to somatotypic, emotional, and cognitive centers of the central nervous system, producing a variety of interpretations to the stimulus based on prior learning and the individual’s cognitive and emotional state. In turn, the central nervous system can inhibit or facilitate the degree of incoming signals via the gate control system. Several neurotransmitters have been found to play a role in these activities, including vasoactive intestinal polypeptide, serotonin, substance P, nitric oxide, cholecystokinin, and the enkephalins.

Psychoneuroimmunology The effects of stress on immune function and disease susceptibility have been clearly demonstrated.20Other studies indicated that psychosocia1 factors can reduce (through anxiety) or enhance (through social 14, l7 Although psychoimmune effects may support) immune re~ponse.~, help account for the waxing and waning of disease conditions, these effects may diminish as the disease progresses. This possibility could explain the contradictory data on the role of stress in inflammatory bowel disease, particularly after the disease is fully e~tablished.~ The principal effectors of the stress response include corticotropinreleasing hormone and the locus caeruleus-norepinephrine systems in the central nervous system. Both are influenced by numerous positive and negative feedback systems that allow both behavioral and peripheral adaptation to ~ t r e s s It . ~has been proposed that disruption in the hypothalamus-pituitary-adrenal system can lead to behavioral and systemic disorders as a result of either increased (e.g., Cushing’s syndrome, melancholic depression, susceptibility to infection) or decreased (e.g., adrenal insufficiency, rheumatoid arthritis, chronic fatigue syndrome, posttraumatic stress disorder) hypothalamus-pituitary-adrenal axis activity?

Modifiers of Illness After an illness is established, sociocultural norms (i.e., explanatory models), family beliefs, personality, major stress, abuse history, daily hassles, and the patient’s previous experiences (including parental responses) with illness all affect how the patient reacts to it. This reaction, in turn, leads to these factors affecting the outcome of illness. Nevertheless, this reaction can be attenuated through certain coping strategies.

PSYCHOLOGICAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS

897

Therefore further attention to the psychosocial feature of gastrointestinal illness is likely to improve the patient’s clinical condition. Culture and Family

In a study in a New York City hospital in the early 1950s, firstgeneration and second-generation Jews and Italians had the greatest reaction to pain, whereas Irish and elderly Americans were more stoic. Furthermore, although Italians patients were satisfied with pain control, Jewish patients needed to know more about the pain and its consequence~.~~ Personality

There was a strong belief during the psychoanalytic era that “in the biologically predisposed host, disease would develop when environmental stress was sufficient to activate the psychological conflict.”l”It is now thought that the idea of specific personalities being related to medical illness is too simplistic; the effects of psychological disturbances are general and not particular to a specific disease. Psychiatric Diagnoses

Screening for psychiatric comorbidity is essential for many reasons. There is a strong association between psychiatric diagnoses and chronic functional pain.27Walker et alZ8found that 24% of patients with chronic abdominal pain have depression, 10% have panic disorder, and 12% to 64% have somatization disorder. Screening for psychiatric disorders is cost-effective because it reduces the consumption of medical services and improves outcomes.2In addition, it is ethically mandated to relieve suffering induced by psychiatric disorders. Many screening tools can be used for this purpose. These tools can help in personality measurement (Minnesota mutiphasic personality inventory [MMPI]; Eysenck personality inventory [EPI]; neuroticism, extroversion, openness personality inventory [NEO]; or million clinical multiaxial inventory [MCMI]) or in cases of multiple psychiatric symptoms (symptom checklist 90 [SCL-901 or profile of mood states [POMS]). Although some psychiatric diagnoses may be associated with certain gastrointestinal diagnoses (e.g., panic disorder with irritable bowel syndromez2),they are not discriminatory. The most common disorders are depressive (including dysthymia), anxiety (including panic), somatoform (including somatization and chronic pain), and factitious (including laxative abuse). Standard criteria for diagnosis of psychiatric diagnoses are avai1able.l The history of abuse (physical or sexual) should be considered in all patients presenting with severe or refractory illness (particularly involving abdominal and pelvic pain) or numerous physical complaints beginning early in life.12 Psychiatric consultation should be considered when psychological factors strongly contribute to the illness, regardless of the medical diagnosis.

898

HIBA & McCALLUM

Psychological Distress Psychological distress lowers pain threshold and leads to health care seeking for patients with functional bowel disturbances or structural disease. Stressful Life Events Life stress has been correlated with functional gastrointestinal symptoms. Evidence of the relationship of life stress to activation of structural disease is compelling (based on retrospective studies and possibly psychoimmunologic mechanisms), although not yet definitive. Social Support and Coping Social supports buffer the adverse effects of stress on illness, reducing the distress and therefore helping the patient to cope with the illness. THE ART OF THE INTERVIEW

The interview is the most important aspect of the relationship between a physician and his or her patient. It allows the physician access to the most intimate details about the patient. The physician can make this a pleasant part of the whole encounter, increasing the overall satisfaction of the patient and giving the physician a chance to feel comfortable about discussing different issues without hesitation. By this, the physician encourages patients’ self-awareness and provides possible behavioral treatments that may ameliorate future symptom flareups. The interviewer should not use the interview as a tool to show domination. This approach leads to a frustrated patient who gives away little information, making the diagnosis and treatment difficult to achieve. Because of the many psychological aspects of functional gastrointestinal disorders, the interview of these patients is even more challenging. There are several common mistakes that physicians may make when dealing with patients with functional gastrointestinal disorders. The physician may invalidate the patient by stating that the patient’s complaint is nothing serious. The physician may raise doubts about his or her confidence and competence by stating that he or she will order a few tests to be sure there is no problem, but he or she believes the tests will be normal. The physician can create an adversarial situation if he or she confronts the patient by stating that the problem is due to stress. Certain essential features of the interview can improve the physician-patient relationship and probably achieve a better outcome. These features include listening actively to the patient, identifying the agenda(s), acknowledging the symptom(s), validating the patient’s feelings without overreacting, educating and reassuring the patient, negotiating with the patient to help him or her take responsibility, and know-

PSYCHOLOGICAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS

899

ing one’s own limitations. Behaviors affecting the interview and the physician-patient relationship are summarized in Table 2. APPROACH TO MANAGEMENT Forming a Therapeutic Physician-Patient Relationship The strategy of forming a therapeutic physician-patient relationship should be individualized. The physician should assume a less dominant and more negotiating role. The physician should encourage a relationship based on shared responsibility. The physician should elicit and validate the patient’s beliefs, concerns, and expectations; offer empathy when needed; clarify misunderstandings; and provide education. The physician should be careful not to provide premature, inadequate, or inappropriate reassurance. This type of reassurance can be perceived as insincere or as a lack of thoroughness by the physician. Although the physician should be responsive to the patient’s needs and requests, this does not mean going along when it is not in the patient’s best interest. Disability, for example, may be counterproductive because the patient may lose the incentive to reestablish wellness and return to gainful employment. It is also necessary to avoid ambiguous behaviors that feed the patient’s doubts or fears, such as ordering studies just to be sure. Not infrequently a patient, at the end of the visit, may bring up new complaints. If this is a recurrent problem, the physician should

Table 2. PHYSICIAN BEHAVIORS AFFECTING INTERVIEW Behavior

Facilitating Effect

inhibiting Effect

Nonverbal Clinical environment Eye contact Body posture Head nodding Body proximity Facial expression Touching

Private, comfortable Frequent Direct, open, relaxed Helpful if well timed Close enough to touch Interest, empathy, understanding Helpful when used to communicate empathy

Noisy, physical barriers Infrequent or constant Body turned, arms folded Infrequent or excessive Too close or too distant Preoccupation, boredom, disapproval Insincere if not appropriate or properly timed

Open-ended to generate hypothesis Close-ended to test hypothesis Use of patient‘s words Fewer questions and interruption Nonjudgmental Follows lead of patient‘s earlier responses Uses a narrative thread Appropriate silence Appropriate reassurance Elicits psychosocial data in a sensitive and skillful manner

Rigid or stereotyped style Multiple choice or leading questions Use of unfamiliar words More questions Follows preset agenda or style HPI+PMH+ROS+Psych Frequent interruptions Premature or unwarranted reassurance Ignores psychosocial data or uses verbal probes

Verbal Question forms

Question style

900

HIBA & McCALLUM

consider psychosocial causes for this behavior (such as fear of loss or rejection or need to control). This behavior can be corrected by setting a time limit to the visit, after which the physician should nonverbally indicate the end of the visit. Remaining issues are to be discussed at the next visit. If the physician is consistent in this approach, the patient will accept the time-structured visit, provided that the physician maintains a commitment to continuing care. Psychopharmacologic Medications

Psychopharmacologic medications may be indicated for treatment of a primary psychiatric disorder but can also be used to treat selected patients with chronic gastrointestinal complaints. Antidepressants

Antidepressants can be used to treat chronic pain (via endorphin activation of corticofugal pain inhibitory pathways24),panic attacks, eating disorders, primary depression, and secondary depressive symptoms associated with chronic medical illness.8A therapeutic trial should be considered for patients with any of the aforementioned syndromes, especially if they are associated with deterioration of daily functions or with vegetative activities (such as weight loss, poor appetite, or lack of energy). The dosage should be maximized over 2 to 3 weeks and maintained for 3 to 6 months. A poor clinical response can result from relatively low dosages. Anxiolytics

Anxiolytics reduce fear and anxiety. Therefore they can be used on a short-term basis for patients with stress-induced flareups of bowel disturbances. The risks of sedation, habituation, withdrawal rebound, and drug interaction should always be kept in mind. Anxiolytics also may decrease serotonin levels and lower pain threshold, or, by stimulating y-aminobutyric acid receptors, they may contribute to depression. Antipsychotic Drugs

Antipsychotic drugs are used primarily to treat disturbances in thought, perception, and behavior in psychotic patients. They may have a role in psychotic or delusional disorders presenting as gastrointestinal disorders, but psychiatric consultation is recommended. Opiates

Opiates have no role in treating patients with chronic pain or psychiatric disturbances because of the potential for abuse and dependency.

PSYCHOLOGICAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS

901

Psychotherapy

The patient must accept psychological care as relevant to personal needs rather than “to prove I’m not crazy,” so it should be determined through an assessment of the personal, social, and economic hardship of the illness. Psychotherapy should be individualized and tailored to each case (insight-oriented, group therapy, crisis intervention, or family counseling). Behavioral Treatments

Behavioral treatments are safe, noninvasive, and cost-effective techniques that help to reduce anxiety and pain levels thereby improving pain control. Relaxation can be facilitated through a variety of techniques, including biofeedback, and meditation. Systematic desensitization is a modification of the relaxation response. It helps ameliorate dysfunctional responses. It has been successfully used in a patient with protracted vomiting.z1It was also found that cognitive-behavioral therapy is effective for patients with bulimia and other compulsive disorders. This therapy involves identifying stressors and learning new ways of coping with them. Specific behavioral treatments are also available. Biofeedback can help patients with fecal incontinence, pelvic floor dy~synergia,2~ and solitary rectal ulcer syndrome.26Transcutaneous nerve stimulation, physical exercise, and acupuncture may help control chronic pain through stimulation of inhibitory pain pathways or release of endorphin. Behavioral treatment techniques have facilitated weaning patients off narcotics in an approach modified from Fordyce.15 This approach involves blind gradual decrease in the dosage of narcotics on an inpatient basis while maintaining the exact color, taste, and volume of the vehicle. Antidepressants and clonidine are introduced to the patient gradually during the decrease in narcotics. Patients are also asked to increase their activity and exercise levels. Bowel retraining is another example of how behavioral modification can help patients who are laxative dependent. In this case, all stimulant laxatives are discontinued. The patient is provided with a high-fiber diet or fiber supplement with an osmotic laxative and then is asked to sit on the commode every morning just after breakfast (this includes tea or coffee) for 15 to 20 minutes. While on the commode, the patient should read for relaxation. There should be no obligation to perform. The effort is only to identify a time at which bowel function can naturally resume. If the patient does not have a bowel movement in 72 hours, he or she takes an enema if warranted by the buildup of symptoms.8 Notes to the Physician

Dealing with uncertainty is always uncomfortable. Pathology cannot be found in many of these patients, however.16,25

902

HIBA & McCALLUM

The pain is real; and the symptoms are real, although pathology cannot be found. The patient senses when the physician stops believing him or her and can become less cooperative. The physician must not react to the patient. The patient is frustrating the physician. Nevertheless, the physician must keep in mind that this behavior is part of the illness. Although it is important to remain vigilant to new diagnostic and therapeutic possibilities, the decision to undertake them should be based on objective assessment of the data rather than the patient’s demands. Resetting treatment goals, coping with the complaints rather than completely eradicating them, is an acceptable option. The physician should set personal limits; the frequency and length of office visits should be established and adhered to. The patient should be encouraged to take a more active role in health care by making choices about the treatment. If the physician needs help, he or she should request it (refer this patient to the gastroenterology team at a major university center). References 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4 (DSM-IV). Washington, DC, American Psychiatric Association, 1994 l a . Alexander F: Psychosomatic Medicine: Its Principles and Applications. New York, WW Norton, 1950 2. Belwett A, Allison M, Calcraft B, et al: Psychiatric disorders and outcome in irritable bowel syndrome. Psychosomatics 37155-160, 1996 3. Bradley LA, Richter JE, et al: The relationship between stress and symptoms of gastroesophageal reflux: The influence of psychological factors. Am J Gastroenterol 8811, 1993 4. Chrousos GP: The hypothalamic-pituitary-adrenal axis and immune-mediated inflammation. N Engl J Med 332:1351,1995 5. Cohen S, Tyrrell AJ, Smith AP: Psychological stress and susceptibility to the common cold. N Engl J Med 53:345, 1991 6. Drossman DA: Clinical research in the functional digestive disorders. Gastroenterology 92:1267, 1987 7. Drossman DA: Psychosocial factors in ulcerative colitis and Crohn’s disease. In Kirsner JB, Shorter RG (eds): Inflammatory Bowel Disease, ed 4. Baltimore, Williams & Wilkins, 1995, p 492 8. Drossman DA: Psychological factors in the care of patients with gastrointestinal disorders. In Yamada T (ed): Textbook of Gastroenterology, ed 2. Philadelphia, JB Lippincott, 1995, p 620 9. Drossman DA: Psychological factors in gastrointestinal disorders. In Sleisenger & Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management, ed 6. Philadelphia, WB Saunders, 1997 10. Drossman DA, Clouse R, Olden K, et al: Chronic abdominal pain: What to do when everything else fails. Seattle, WA, American College of Gastroenterologists 61st annual scientific meeting, 1996 11. Drossman DA, Sandler RS, et a1 Bowel patterns among subjects not seeking health care: Use of questionnaire to identify a population with bowel dysfunction. Gastroenterology 83529, 1982

PSYCHOLOGICAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS

903

12. Drossman DA, Talley NJ, et al: Sexual and physical abuse and gastrointestinal illness: Review and recommendations. Ann Intern Med 123782-794, 1995 13. Drossman DA, et al: Identification of subgroups of functional bowel disorders. Gastroenterol Int 3159, 1990 14. Fawzy FI, Fawzy NW, Hyun CS, et al: Malignant melanoma: Effects of an early structured psychiatric intervention on recurrence and survival 6 years later. Arch Gen Psychiatry 50:681, 1993 15. Fordyce WE: Behavioral methods in medical practice. In Karasu TB, Steinmuller RI (eds): Psychotherapeutics in Medicine. New York, Grune & Stratton, 1978, p 83 16. Fox RC: Training for uncertainty. In Merton R, Reader D, Kendall T (eds): The Student Physician. Cambridge, Harvard University Press, 1957, p 207 17. Glaser R, Kiecolt-Glaser JK, et al: Stress-induced modulation of the immune response to recombinant hepatitis B vaccine. Psychosom Med 5422, 1992 18. Hiba MR Chronic functional abdominal pain. University of Kansas, GI grand rounds, 1997 19. Jones D M Functional gastrointestinal disorders and irritable bowel syndrome. In McNally P (ed): GI/Liver Secrets. Philadelphia; Hanley & Belfus, 1995 20. Kiecolt-Glaser JK, Glaser R Psychoneuroimmunology and health consequences: Data and shared mechanisms [review]. Psychosom Med 57269, 1995 21. Latimer PR, Malmud LS, Fisher RS: Gastric stasis and vomiting: Behavioral treatment. Gastroenterology 83:684, 1982 22. Lydiard RB, Greenwald S, et al: Panic disorder and gastrointestinal symptoms: Finding from the NIMH epidemiologic Catchment Area Project. Am J Psychiatry 151:64, 1994 23. Mitchell CM, Drossman DA: Survey of the AGA membership relating to patients with functional gastrointestinal disorders. Gastroenterology 921282, 1987 24. Onghena P, Houdenhove BV Antidepressants-induced analgesia in chronic non-malignant pain: A meta-analysis of 39 placebo-controlled studies. Pain 49:205, 1992 25. Svendsen JH, Munck LK, Andersen J R Irritable bowel syndrome: Prognosis and diagnostic safety: A 5-year follow-up study. Scand J Gastroenterol20:415, 1985 26. Vaisey CJ, Roy AJ, Kamm MA: Prospective evaluation of the treatment of solitary rectal ulcer syndrome with biofeedback. Gut 41:817-820, 1997 27. Walker EA, Katon WJ, et al: Comorbidity of gastrointestinal complaints, depression and anxiety in the epidemiologic catchment area (ECA) study. Am J Med 9226530S, 1992 28. Walker EA, Katon WJ, et al: Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain. Psychosomatics 36:531-540, 1995 29. Whitehead WE: Behavioral medicine approaches to gastrointestinal disorders. J Consult Clin Psycho1 60605, 1992 30. Zborowski M Cultural components in responses to pain. J Social Issues 8:16, 1952

Address reprint requests to Richard W. McCallum, MD Department of Medicine Division of Gastroenterology and Hepatology Kansas University Medical Center 3901 Rainbow Boulevard Kansas City, KS 66160