The undeniable mind-body connection in gastrointestinal health

Daphne Spyropoulos, PhD, of Cleveland Clinic, is among a handful of psychologists practicing in a highly specialized niche: working with patients who have gastrointestinal (GI) issues. Her practice focuses on supporting patients who are being treated for inflammatory bowel diseases (IBDs) such as ulcerative colitis and Crohn’s disease. Her role on the treatment team is key: Along with sometimes debilitating physical symptoms, many GI conditions are associated with a heightened risk of mental illness. Anxiety and depression can further disrupt a person’s quality of life and, in turn, worsen IBD symptoms. With the support of the Fields Galley Private Foundation, she also founded the Women’s Health and IBD Clinic within Cleveland Clinic’s Digestive Disease Institute to support women with fertility, pregnancy, and menopause-related concerns.

We asked her to talk in depth about how she works with patients, the shame and stigma and other complexities that surround GI issues, and why integrated care should be the norm.

Clinical health psychology is at the intersection of medicine and psychology, and GI psychology is a specific example of that, focusing on the two-way relationship of gut-brain interactions.

We look at how the brain affects the gut—for example, we know that anxiety can cause diarrhea or other GI symptoms. But we also study how the microbiome composition, specifically inflammation from GI conditions, might contribute to conditions like depression and anxiety. These can certainly exist outside of GI conditions, but GI psychologists focus on helping people who have concerns with their digestive health.

Gut-brain research is still new, which plays a role, but stigma is also part of it. Most things that have to do with going to the bathroom are stigmatized—that’s why GI is not necessarily a popular field among medical providers. There can be a lot of shame associated with issues like diarrhea or incontinence.

Psychologists also don’t learn a lot about medicine in PhD programs, outside of the biological bases of behavior. Psychologists in training may not know they can carve out their career path based on their interests. I had to tailor my externships and practicums to incorporate what I wanted to learn, but it wasn’t easy. Once I became interested in GI health, I had to persuade the United European Gastroenterological Society to let me join a course about fecal microbiota transplants. Those instructors told me it’s not common for psychologists to ask to join courses like this.

We can apply evidence-based psychological interventions to help improve patients’ physical symptoms. Cognitive behavioral therapy (CBT) and “gut-directed relaxation,” including mindfulness and deep breathing, can help alleviate GI pain or bathroom urgency, both of which are linked to anxiety. Research supports that CBT can reduce physical inflammation in patients, which can also help mitigate symptoms.

How we address the emotional aspect of living with a GI condition depends on their presenting problem, whether generalized anxiety disorder, phobias, or depression, among others. But even outside of these diagnoses, we play an important supportive role in navigating chronic illness. Clinical health psychologists have experience working with patients who are frequently hospitalized due to the complexity of the disease, see doctors frequently, and take numerous medications. We can help people adhere to their treatment plan and prepare for appointments or procedures.

We can also appreciate how living with these conditions can affect other areas of life. With IBD, it’s common to struggle with holding a job. People may feel isolated because they don’t attend social events due to their symptoms. We work a lot on dealing with shame, advocating for oneself in relationships, and at work.

Every patient has a history that has nothing to do with their GI condition, and we play a role in reminding physicians of the full picture so they can provide better treatment.

For example, I often meet with patients to talk about their treatment regimen. If someone needs a colostomy bag, they may be concerned with sexual intimacy and body image. I ensure the medical provider is aware of any such concerns so they can tailor care accordingly, whether exploring other options with patients or understanding the risks of not doing something. Feeling a sense of control amid uncertainty can help improve patients’ physical and mental well-being.

I can also work with medical providers to ensure trauma-informed care. For example, at the Women’s Health and IBD Clinic within Cleveland Clinic, we prescreen for sexual trauma in all patients with IBD. With most GI conditions, procedures can be invasive. If a medical provider knows a patient has sexual trauma, they can tailor care accordingly by, for instance, offering alternatives to invasive procedures done under general anesthesia. One of my colleagues at Cleveland Clinic, Katherine Falloon, MD, built an ultrasound clinic for IBD, and we can offer it as an alternative to colonoscopies when appropriate and in selected patients who may otherwise refuse care.

As part of the Women’s Health and IBD Clinic, I am giving lectures to our GI and colorectal surgery fellows about best practices in providing patients with trauma-informed care. I am also incorporating this into my work at Cleveland Clinic Lerner College of Medicineopens in new window within the Case Western Reserve University School of Medicine. Always ask patients if they are comfortable with a physical exam that could involve gentle physical contact, such as examining their neck for nodules or feeling their stomach for bloating. Doctors often forget these things, but it makes a big difference in helping them build rapport with patients.

If you have patients with a chronic illness who may benefit from seeing a therapist, I recommend consulting the Board of Clinical Health Psychologyopens in new window website. They have a directory with board-certified providers who have experience working in hospitals or with patients who have chronic health conditions.

For GI psychologists specifically, I refer people to the Rome Foundationopens in new window, an organization that disseminates scientific education about GI disorders, and they have a directory for gastropsych providers.

Research shows that when psychologists are included on medical teams, the outcomes are better. Patients have fewer rehospitalizations, and they adhere to medication much better.

Psychologists’ training makes them great point-people for communication between health care providers and patients. We can ask patients questions that complement what physicians ask, such as whether there are any cultural issues that may impact their care.

Being in the hospital can be intimidating for some people. If someone feels vulnerable already, they may lose the ability to take in what their physicians say, so they can miss a lot of information. We can help confirm that patients understand what their doctors say and help them advocate for themselves in the process.

It’s a fascinating field, and I hope more GI psychologists become available so that integrated care becomes the standard of care.