IBD and Anxiety

Inflammatory bowel disease (IBD) is a term that primarily refers to two diseases of the intestines: Crohn’s disease and ulcerative colitis. These diseases cause chronic inflammation, and include symptoms such as severe abdominal pain, diarrhea, and rectal bleeding. In Crohn’s disease, the inflammation can be anywhere in the digestive tract, and can extend right through the entire thickness of the bowel, occurring in multiple patches or one large patch. In ulcerative colitis, the inflammation is limited to the inner mucosa and begins at the anus, with the disease continuously progressing upward through the colon only.

The cause of IBD is still undetermined but there is considerable research evidence suggesting that interactions among environmental factors, intestinal microorganisms, immune dysregulation, and genetic predisposition are responsible.

A recent study1 analyzed the link between IBD and anxiety by looking at many studies published on the subject (meta-analysis), and found that along with the severe physical symptoms, patients with IBD frequently experience psychological comorbidities. One study found that up to 40% of those with IBD experience abnormal levels of anxiety. In another study, anxiety affected between 29-35% of IBD patients in remission, but this drastically increased to 80% of IBD patients during a flare-up. This anxiety prevalence is much higher than expected by chance, and it is especially high in patients with Crohn’s disease. In IBD, the severity of symptoms can be a factor in developing anxiety, although in some, the anxiety came first.

Emerging research shows that anxiety can even trigger a flare-up in IBD patients. One study found active mucosal inflammation to be associated with an increase in psychological symptoms. This research is helpful, because it shows just how important it is to get inflammation under control. Individuals with IBD who receive adequate treatment and stay in remission are less likely to experience anxiety.

There are certain risk factors that make someone with IBD more likely to develop an anxiety disorder, including psychological stress, increasing age, severe and active disease, surgery, lack of disease education, and poor socioeconomic status.

However, the patients at highest risk for developing anxiety are those who have had an ostomy. Ostomy patients are more likely to have a decreased quality of life and increased psychological problems, but they often don’t receive the psychological help that they need. Dealing with an ostomy can be tough on many aspects of life, and physicians should take steps to ensure that patients receive adequate treatment for all aspects involved.


What is an Ostomy?

The term ostomy refers to the surgical opening created for the elimination of body wastes. When the digestive system ceases to function properly due to disease or injury, a physician may recommend removing or bypassing portions of the small intestine or colon. When the surgeon removes or bypasses these sections, sometimes it may no longer be possible to eliminate waste (have a bowel movement) from the usual anatomic route. The surgeon will then re-direct the end of the remaining intestinal tract to the surface of the skin; this opening is a “stoma” or ostomy. When the small intestine connects with the surface it is called an ileostomy and when the colon (large intestine) connects with the surface it is called a colostomy. Ileostomies and colostomies may be either temporary or permanent, depending upon the particular situation.


The Influence of Functional GI Disorders

IBD is an organic bowel disease, which means that it has specific, measurable physiological effects on the body. Other disorders, such as irritable bowel syndrome (IBS), are functional conditions, where symptoms occur but there is no obvious physical reason. Typically, psychological symptoms are more common in those with functional GI disorders, so it is common for physicians to screen for anxiety in these patients. However, since IBD is an organic disease, physicians don’t often consider that these individuals experience anxiety, leaving some patients undiagnosed.

Interestingly, physicians frequently use a diagnosis of an organic GI disease to rule out a functional disorder. However, it is possible to have both, and it appears to occur quite frequently. One Australian study found that 66% of IBD patients also met criteria for at least one functional GI disorder, which was especially common in those who had both IBD and anxiety. It is important that physicians recognize the difference between normal IBD symptoms, and those that could be from irritable bowel syndrome or functional dyspepsia.


Treating IBD and Anxiety

The study authors say it is important for physicians to determine whether patients with IBD also have a functional disorder. Differentiating symptoms between the two can be difficult, so they suggest that doctors first look for signs of inflammation, treat those, and then if symptoms remain it could indicate a functional disorder, at which point they should consider treatment for this disorder as well.

Physicians typically involved in caring for IBD patients, such as general practitioners and gastroenterologists, sometimes don’t have much formal training in psychological disorders, and since patients are often hesitant to bring up psychological symptoms due to social stigma, they typically remain undiagnosed and untreated for too long. When IBD patients with an anxiety disorder experience stigma and therefore don’t seek treatment, it can lead to further disability. It is very important that physicians are aware of the increased risk of anxiety in IBD patients, and should be prompt in detecting and treating any coexisting anxiety disorders. Patients also have a responsibility to speak up and ask for help if they perceive that anxiety is a problem for them.

The study authors recommend physicians use formal screening questionnaires to detect anxiety in IBD patients. They suggest a few different types of questionnaires, preferably something simple, that is long enough to be accurate, but not so long that it is burdensome to the patients, could be an effective way to detect anxiety in IBD patients.

For patients who are anxious, management should involve a gastroenterologist and a psychologist or psychiatrist. Treatment should include medications for IBD along with therapy and medications for anxiety. However, studies show that psychological treatments have no benefit for those with IBD who don’t have anxiety or other psychiatric disorders, so it is important to have efficient screening methods to determine which patients should receive specific treatments.

Treating anxiety can even have extra beneficial effects by reducing IBD symptoms. One study found that using cognitive behavioural therapy (CBT) in adolescents with IBD and anxiety not only reduced anxiety, but also improved pain and disease severity in IBD. Studies have long supported the use of CBT in irritable bowel syndrome as well.

If you are an IBD patient and are concerned that you might have anxiety or a functional gastrointestinal disorder, speak with your doctor.


5 Item Anxiety and Depression Detector1

Have you:

  1. Had a spell or attack where all of a sudden you felt frightened, anxious, or uneasy?
  2. Been bothered by nerves or feeling anxious or on edge for 6 months or more?
  3. Had a problem being anxious or uncomfortable around people?
  4. Had recurrent dreams or nightmares of trauma or avoidance of trauma reminders?

Over the past 2 weeks, have you:

  1. Felt down depressed or hopeless with little interest or pleasure in doing things?

First published in the Inside Tract® newsletter issue 195 – 2015
Image Credit: © bigstockphoto.com/igor stevanovic
1. Bannaga AS et al. Inflammatory bowel disease and anxiety: links, risks, and challenges faced. Clinical and Experimental Gastroenterology. 2015:8;111-7.