Educating Patients on the Mental Health, GI Connection

This article was last updated on Oct. 5, 2022, to include current information and research. 

As a physician, you can inform your patients on the links between the brain and gut, and plan treatment options that can effectively tackle the root causes of their discomfort. Patients who experience gastrointestinal pains or disorders may not be aware that their symptoms may be impacted by their mental health.

A strong connection exists between the brain and the digestive tract. In fact, the connection is so strong that it can be difficult to tell where one ends and the other begins. Patients with gastrointestinal (GI) disorders often experience stress, and those with anxiety disorders frequently have digestive issues. An estimated 40 to 60 percent of those with irritable bowel syndrome (IBS) have a psychiatric disorder, such as depression or anxiety. The connection between the gut and brain is known as the “gut-brain axis.” Research between this connection has shown that biochemical reactions can trigger GI-related symptoms and worsen existing disorders.

Determining whether a patient’s symptoms are the result of a physiological problem, or a psychosomatic one can be tricky for GI fellows and experienced gastroenterologists alike.

Research

Throughout history there has been a long tradition of linking disorders to mental health issues. Prior to the development of flexible endoscopy in 1958, allowing gastroenterologists to see inflammation and ulcers in the colon, practitioners assumed the symptoms of ulcerative colitis (UC) were caused by unresolved emotional problems. Psychologists believed the issues came as a part of Freudian regression stemming from traumas occurring during patient’s toilet training.

Through the 1970’s, researchers continued to investigate the relationship between GI problems and mental health. A 1990 literature review including 138 students failed to recognize an association between psychological factors and UC. As a result, UC was recognized as an organic disease process. This recognition in turn shifted the focus away from the role of stress and mental health disorders on GI health.

Current research has solidified the relationship through investigation into the gut-brain axis. One 2010 study shows that psychological trauma and irritable bowel syndrome (IBS) are often co-morbid conditions, for example, while another study establishes a connection between mental health problems and gastrointestinal disorders.

Ongoing research from Johns Hopkins Medicine has also shown that the gut-brain relationship can also work in reverse.

“Our studies and others show that signals sent by the brain to the gut may also work the other way around,” Jay Pasricha, M.D., Director of the Johns Hopkins Center for Neurogastroenterology said. “Researchers are finding evidence that irritation in the gastrointestinal system may send signals to the central nervous system that triggers mood changes.”

Research conducted on the gut-brain relationship has also opened the door for new treatment options for common GI disorders, such as IBS, such as prescribing antidepressants.

“Our two brains ‘talk’ to each other, so therapies that help one may help the other,” Pasricha said. “In a way, gastroenterologists (doctors who specialize in digestive conditions) are like counselors looking for ways to soothe the second brain.”

Which Comes First – Stress or GI Problems?

Living with chronic, unpredictable, and often uncomfortable digestive symptoms can have a significantly negative effect on daily life – it can also be quite stressful. GI symptoms, such pain, diarrhea, and constipation can interfere with nearly every aspect of a patient’s activities; they can also prevent the patient from engaging in meaningful activities that support physical and mental wellness. The constant and uncomfortable nature of many digestive issues causes many patients to experience a wide range of emotions. These range from anxiety and stress to agitation and depression.

The gut contains its own intrinsic enteric nervous system (ENS) that communicates directly with the central nervous system (CNS). In fact, there are about 100 million neurons in the small intestine alone, which means the ENS is the largest collection of neurons outside the brain. The ENS is in constant communication with the brain; stress can affect this brain-gut communication to make the CNS more sensitive to pain, bloating, and other discomfort in the gut.

Microbiome

The gastrointestinal tract also contains bacteria that can affect the health of the GI system. It can also influence the ability to think and feel emotions. Stress can cause changes to this sensitive gut microbiome, and these fluctuations can in turn influence mood.

The American Psychological Association (APA) recognizes the connection between psychological stress and GI disorders. The APA also acknowledges the long-held theory that early life stress can affect nervous system development and the physiological reactions to stress in ways that can increase the risk for GI problems later in life.

Stress can change eating habits or increase the use of tobacco and alcohol to increase the risk of acid reflux, for example. Acute stress can increase the severity of heartburn pain, make swallowing difficult, or increase the amount of air swallowed while eating to cause belching, flatus, and bloating. Stress can also change the gut’s microbiome, and decrease gastric emptying while accelerating colonic transit.

When a Digestive Disorder is Not a GI Problem

In some situations, GI physicians must look beyond the gut, especially when scans such as imaging and lab tests rule out typical digestive disorders. Certain clues can help gastroenterologists identify situations in which anxiety disorders are triggering GI problems. A clinician can ask the patient about any burdensome life events, for example, or find out if the patient has recently experienced anxiety, depression, or stress.

The clinician can also look for physical signs of stress, which can include:

• Dyspepsia
• Constipation, diarrhea
• Forgetfulness
• Frequent aches and pains
• Headaches
• Lack of energy or focus
• Stiff jaw or neck
• Fatigue
• Sexual problems
• Hypersomnia or insomnia
• Use of alcohol or drugs to relax
• Changes in weight

Different Routes

To improve patient outcome, the gastroenterologist may refer patients with anxiety-related GI problems to a psychologist. During the consultation, the psychologist or mental health professional will assess the patient’s symptoms and assess the role stress and anxiety play in those symptoms. The psychologist will identify challenges the patient has with managing their GI and mental health symptoms. The mental health professional will also determine if counseling should be included in the patient’s treatment, and work with the gastroenterologist to create a personalized treatment plan for the patient.

A 2021 article from Harvard Health showed that patients who underwent combined treatment, including therapy with traditional medicine, experienced improved results versus those who received treatment through traditional medicine alone.

A number of treatments for stress and anxiety are available. Meditation and mindfulness-based stress reduction (MBSR) is a program that helps people become more aware of how negative thoughts can affect physical symptoms. MBSR can reduce stress and anxiety, improve memory and focus, calm emotional undulations, and help patients develop greater resilience to stressors. Cognitive behavioral therapy (CBT) is a type of talk therapy that challenges and changes unhealthy cognitive distortions and behaviors to improve coping strategies. Acupuncture and massage can also help ease stress to alleviate GI symptoms.

Gastroenterologists who make the connection between anxiety disorders and gastrointestinal problems can help patients discover the underlying causes of their symptoms, and build a treatment plan to create a healthier, more comfortable life.