Behavioral Therapy for IBD and Functional GI Disorders

Educational Objectives

The goal of this program is to improve the management of patients with functional gastrointestinal disorders. After hearing and assimilating this program, the clinician will be better able to:

1. Recommend behavioral therapy as part of multidisciplinary care for inflammatory bowel disease and functional gastrointestinal disorders.
2. Identify which patients with inflammatory bowel disease and functional gastrointestinal disorders would benefit from referral to a gastrointestinal psychologist.

Summary

Behavioral therapy for gastrointestinal (GI) disorders: American Gastroenterological Association currently recommends consideration of psychological therapy for patients with irritable bowel syndrome (IBS) with moderate to severe disease; patients with IBS difficult to treat; GI psychologist requires additional training in behavioral therapy specific to GI disorders

Behavioral interventions: excellent comprehensive treatment to add for GI patients difficult to treat; advantage — usually highly effective; disadvantages — require active participation and motivation from patient; lack of GI psychologists in community

Comprehensive and holistic care in IBD: meta-analysis (2017) — shows that cognitive behavioral therapy (CBT), gut-directed hypnosis, and mindfulness-based interventions effective for patients with anxiety, depression, and chronic abdominal pain, however, treatments must be available in long term; even patients without clinical depression or anxiety can benefit from targeting negative health behaviors and improving overall physical health and self-management

Concept of IBS-IBD overlap: in some patients with inflammatory bowel disease (IBD), signs of disease indicate patient in clinical remission, but still have symptoms (eg, residual abdominal pain related to functional bowel symptoms); almost 60% of patients with Crohn disease (CD) and ≈40% of patients with ulcerative colitis (UC) have persistent symptoms, despite IBD being in remission

Targets of treatment: self-management and self-efficacy; depression and anxiety; functional overlap; improving quality of life; self-management — every patient with IBD must be effective self-manager; patients with IBD typically only spend ≈3 hr per year with gastroenterologist; stress detrimental to IBD; fear — extended length of time before diagnosis can lead to fear and distrust of medical providers; important to address fact that disease in remission although still symptomatic, and reassure patients additional treatment options available; patients may decrease intake of food because of fear that food causes additional or exacerbation of symptoms, resulting in lower body mass index (referral to GI dietitian recommended); advise on strategies for eating and identifying foods that may exacerbate symptoms; CBT — can help patient deal with complexities and unknown, uncontrollable, and unpredictable aspects of chronic illness like IBD, and provide strategies for coping with GI-specific anxiety; one of initial goals of treatment to connect patient with community of other patients to communicate with and develop relationships

Rumination syndrome and gastroparesis: difficult to treat; for rumination syndrome, diaphragmatic breathing recommended to improve air swallowing; gastroparesis not easily amenable to CBT or gut-directed hypnosis, but these interventions can be effective

Functional GI disorders (FGIDs): conventional therapies often inadequate, and patients often considered difficult to treat and high utilizers of health care; often necessary to approach FGIDs from comprehensive, multimodal, and multidisciplinary perspective; psychological therapies have demonstrated excellent efficacy, particularly CBT, gut- and esophageal-directed hypnosis, and mindfulness-based interventions that include relaxation training

Cognitive behavioral therapy: encompasses multiple modalities; psychoeducation — good starting point; for patients with IBS, explain brain-gut connection (strong evidence suggests bidirectional pathway between brain and gut) and reassure them that symptoms “not just in head” (helps build rapport with patients and validate to patient that believe symptoms real); discuss response of body to stress and importance of effective relaxation strategies; diaphragmatic breathing — for patient with urgency and diarrhea, stimulating diaphragm offers relaxation and “massage” of colon and small intestine; for patient with constipation, helps relieve clenching and tensing during bowel movements; other relaxation strategies — progressive and passive muscle relaxation; guided imagery; emphasize to patient that improving management of stress increases ability to address daily tasks with more focus and concentration, and addresses brain-gut pathway; cognitive restructuring — requires active participation from patient to recognize how their thinking affects their feelings and behavior, and be able to decatastrophize their experience of symptoms); problem-solving skills — patients with FGIDs often “chronic inflexible copers”, so beneficial to instill more flexible coping strategies; help patient recognize that even if symptoms present, methods still available for patient to cope more effectively; exposure techniques — patients often avoid stressful situations, so important to develop coping strategies with patient; thought record — during stressful situation, patient tracks what is going on in mind (eg, rates level of anxiety) and determines evidence that supports and does not support initial thought; helps teach patient different way of thinking through stressful situations and come to new conclusion about way of thinking; targets of therapy — GI-specific anxiety; visceral hypersensitivity; symptom hypervigilance; stress sensitivity; pain catastrophizing; inflexible coping; avoidance and safety behaviors

Gut-directed hypnosis: evidence-based intervention for management of IBS; 7-session protocol (patient and provider meet once every other week, and in between, patient provided with CD recording to practice at home); advantages — number needed to treat 2; cost-effective; some evidence showing applicability for groups; effects durable ≤1 yr after initial 7 sessions; disadvantages — time-consuming (typically lasts ≈3 mo); home-based protocols not as effective as in-office ones; some stigma around hypnosis

Ideal patients for behavioral therapy: motivated to participate in therapy; open to working with GI psychologist; believe stress contributing factor to disease

Esophageal-directed hypnosis: protocols available to address symptoms of choking, globus pharyngis, dysphagia, and functional heartburn; shows success in patients who difficult to treat (eg, do not respond to or require proton pump inhibitors) and avoids unnecessary repeat endoscopies that only risk increasing esophageal hypersensitivity

Conclusion: behavioral therapies important part of multidisciplinary care for IBD and FGIDs, with focus on integrated treatment; screening for anxiety, depression, and functional impairment recommended (gastroenterologists and community providers need to be familiar with diagnostic criteria and be prepared to refer early and often); behavioral interventions effective for patients with IBD with depression and anxiety

Readings

Bennebroek Evertsz F et al: Effectiveness of cognitive-behavioral therapy on quality of life, anxiety, and depressive symptoms among patients with inflammatory bowel disease: A multicenter randomized controlled trial. J Consult Clin Psychol, 2017 Sep;85(9):918-925; Berrill JW et al: Mindfulness-based therapy for inflammatory bowel disease patients with functional abdominal symptoms or high perceived stress levels. J Crohns Colitis, 2014 Sep;8(9):945-55; Knowles SR et al: The efficacy and methodological challenges of psychotherapy for adults with inflammatory bowel disease: a review. Inflamm Bowel Dis, 2013 Nov;19(12):2704-15; Leone D et al: State of the art: psychotherapeutic interventions targeting the psychological factors involved in IBD. Curr Drug Targets, 2014;15(11):1020-9; McCombie A et al: Does computerized cognitive behavioral therapy help people with inflammatory bowel disease? a randomized controlled trial. Inflamm Bowel Dis, 2016 Jan;22(1):171-81; Mikocka-Walus A et al: Cognitive-behavioural therapy has no effect on disease activity but improves quality of life in subgroups of patients with inflammatory bowel disease: a pilot randomised controlled trial. BMC Gastroenterol, 2015 May 2;15:54; Mizrahi MC et al: Effects of guided imagery with relaxation training on anxiety and quality of life among patients with inflammatory bowel disease. Psychol Health, 2012;27(12):1463-79; Pittet V et al: Swiss IBD Cohort Study Group. Patients’ information-seeking activity is associated with treatment compliance in inflammatory bowel disease patients. Scand J Gastroenterol, 2014 Jun;49(6):662-73; Schoultz M et al: Mindfulness-based cognitive therapy for inflammatory bowel disease patients: findings from an exploratory pilot randomised controlled trial. Trials, 2015 Aug 25;16:379; Szigethy E: Hypnotherapy for inflammatory bowel disease across the lifespan. Am J Clin Hypn, 2015 Jul;58(1):81-99

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Riehl was recorded at Gastroenterology Update: A Case-Based Approach to Common GI Problems, held September 29-30, 2017, in Dearborn, MI, and presented by the University of Michigan Medical School and its Office of Continuing Medical Education. For information about upcoming CME activities from this sponsor, please visit www.ocpd.med.umich.edu/cme. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GE321402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.