Addressing the Mind, Body, and Spirit in a Gastrointestinal Practice for Inflammatory Bowel Disease Patients

The past decade has witnessed a growing emphasis on the importance and clinical relevance of incorporating a multidisciplinary approach to address patients’ priorities and desires that includes specific attention to mind–body approaches in the treatment of many gastrointestinal (GI) illnesses. This trend may be attributed to mounting empiric evidence indicating that the disease course and even etiology of many functional and organic GI illnesses is best understood by a combination of genetic, physical, physiological, and psychological factors. There also has been increased recognition of the pervasive, psychosocial impact that chronic GI illness may have on the patient’s life and disease course, as well as the benefits of addressing such issues in management of these disorders.1,2 It is thus paradoxic that gastroenterology practices in teaching hospitals and private practices rarely incorporate interventions to address the interaction of mind and body in the treatment of their patients. However, many GI patients often seek to either supplement or even substitute their standard care with alternative approaches. This desire results from dissatisfaction with standard therapies, negative side effects of conventional medication, and/or an attempt to avoid medication and a desire for a greater sense of control over one’s health.3 Simply put, patients seem to prefer a holistic approach, one that considers not merely the body’s specific physical symptoms, but the illness experience in its entirety: mind, body, and spirit. Stress is one of the most important environmental factors that impacts mind, body, and spirit. Although the specific mechanisms by which stress affects the gut are largely unknown, evidence suggests that stress affects GI function through several mechanisms, including activation of the brain-gut axis and modulation of hormonal and neuroimmune pathways.4-6 For example, the stress hormone corticotrophin-releasing factor is involved in the endocrine, behavior, and visceral responses to stress including stress-induced changes in GI motility and intestinal mucosal barrier function. Stress reactivates and exacerbates colonic inflammation in experimental colitis and increases mucosal inflammatory markers in inactive ulcerative colitis (UC) patients by activating mucosal mast cells and disrupting mucosal barrier integrity.4,6 Perceived stress predicts mucosal abnormalities among UC patients,7 an effect that may be caused by stress-induced exacerbation of mucosal inflammatory cascades. These studies provide substantial evidence that stress influences the GI tract and bolsters support for the impact of the long-lasting effects of stress on GI function that could impact the disease course in illnesses such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). Despite compelling experimental data that stress and the mind impact wide ranges of GI functioning and the inflammatory cascade, we still await future studies to see if stress management and holistic therapeutic approaches could indeed impact the disease course of GI illnesses. However, recent studies have suggested that these interventions positively impact patients’ quality of life by at least improving their coping and associated symptoms of depression and anxiety, which are extremely common in patients with IBD and IBS.2 Indeed, mounting evidence suggests that psychotherapy can have a significant impact on both psychological and clinical outcomes measures. Psychotherapy for IBD patients typically has incorporated relaxation and stress management techniques, and selected interventions are based on various theoretic orientations, including psychoanalysis and psychodynamic theory, cognitive behavioral theory, and supportive psychotherapy.2 Most clinicians are keenly aware that coping with a chronic illness, such as IBD and IBS, can be extremely challenging, with a major negative impact on the patient’s quality of life. These patients worry regularly about the numerous uncertainties associated with their disease, such as when the next flare will occur, whether they can control their urge to defecate during social events or at work, whether current medications will cease to be effective, and whether surgery will become necessary. These concerns also impact their interactions with family members, children, coworkers, and friends, resulting in increased difficulties in coping with their disease and contributing to mood disturbances. It is not surprising that IBD patients suffer from symptoms of depression and anxiety as high as 60% to 80% during flare-ups and even up to 35% during remission.8 Interventions helping these patients to confront these difficulties by either exploring their feelings through psychotherapy, or by increasing their awareness of feelings through techniques such as Mindfulness-Based Stress Reduction (MBSR), could improve their illness coping, and this should lead to improved quality of life. Indeed, our recent, unpublished data of 50 patients with ulcerative colitis showed that mindfulness (as measured by the Mindfulness Attention and Awareness Scale9) showed a significant positive correlation with quality of life (rs = 0.49; P < .01). Further studies are needed to show whether these techniques indeed would impact these patients’ lives positively. Nonetheless, the following 2 vignettes show how IBD-specific individual and group psychotherapy as well as MBSR potentially could be useful in the management of a subset of IBD patients; thus practicing gastroenterologists should identify patients with poor coping and comorbid anxiety/depression who could benefit from such interventions.