Implementing psychological therapies for functional GI disorders in children and adults

ABSTRACT

Introduction: Functional GI disorders (FGIDs) are common in adults and children. Psychological factors play an important role in the onset and maintenance of FGIDs and in explaining the associated disability. Psychological treatments such as Cognitive Behavioral Therapy and Hypnotherapy have been found efficacious in FGIDs but Integrating psychological treatments into traditionally medically-oriented care can be challenging.

Areas covered: This review outlines the case for integrating psychological therapies into medical care for FGIDs and examine various models of integrated care that can be adapted to fit specific practice scenarios.

Expert commentary: We advise integrating a psychologist in the care and treatment planning of every patient. Clinic-specific needs dictate how integrated care for patients with FGIDs can be delivered.

KEYWORDS:

• Functional gastrointestinal disorders
• irritable bowel syndrome
• integrated care
• psychological aspects
• cognitive behavioral therapy
• hypnotherapy
• functional abdominal pain
• functional dyspepsia
• constipation
• cyclic vomiting syndrome

1. Introduction

Functional gastrointestinal disorders (FGID) are common disorders affecting both children and adults. They include disorders such as irritable bowel syndrome (IBS), functional constipation, functional dyspepsia, cyclic vomiting syndrome (CVS), and many others. The causes for FGIDs are thought to be multifactorial and explained by a biopsychosocial model, which implies complex interactions between the brain, the gut, and the environment [1]. Alterations have been identified among the broad group of patients with FGIDs in several basic physiological mechanisms, including immune response, motility, and sensation [1], as well as in psychological functioning. Of note, these systems are increasingly understood to be dynamic and interactive with one another. Therefore, treatment should address both biological and psychological aspects of FGIDs in order to be most effective. However, integrating psychological therapies as well as additional treatment modalities such as nutrition, physical therapy, or lifestyle behavior modification training into traditionally medically oriented care can be challenging. This review will outline the case for integrating psychological therapies into medical care for FGIDs and examine various models of integrated care that can be adapted to fit specific practice scenarios.

2. Psychological factors and therapies in FGIDS

A large literature describes the association of psychological factors with FGIDS, including increased psychological distress, somatization, stressful life events, history of sexual and physical abuse, and maladaptive coping [2,3]. A complete overview is beyond the scope of the current article; however, Van Oudenhove and colleagues recently asserted that addressing environmental, psychological, and biological factors ‘is a conditio sine qua non for appropriate treatment’ of FGIDs in their review of biopsychosocial factors implicated in these disorders [4]. It is important to note that psychological factors can have two types of effects on FGIDs. First, they may influence symptoms directly through an association with the onset and maintenance of FGID symptoms [5–7]. Secondly, psychological factors can influence the disability associated with FGIDs. For example, specific psychological factors such as coping and distress have been shown to increase the frequency of physician consultations for symptoms and school/work absences [8–10]. Even in the absence of preexisting psychosocial concerns, behavioral responses focused on pain avoidance can lead to an escalating cycle of pain, disability, and distress.

Given the importance of psychological factors in FGIDs, the efficacy of psychological treatments has been evaluated in FGIDs. Cognitive behavioral therapy (CBT) is effective in treating both the symptoms and disability associated with abdominal pain, IBS, dyspepsia and fecal incontinence [11–14]. Patients learn skills-based strategies for identifying and modifying thoughts, emotions, and behavioral responses so that symptoms are managed adaptively and consistently with medical recommendations. Gut-directed hypnotherapy has also been found to be efficacious in treating abdominal pain-related FGIDs in both children and adults [15] (scripted protocols can be obtained through contacting Dr Van Tilburg), while biofeedback has been associated with decreased symptoms in children with functional dyspepsia and adults with constipation [16,17]. Taken together, there is strong evidence that psychological therapies can be effective in treating primary symptoms including abdominal pain associated with functional conditions as well as coexisting anxiety and depression. Two meta-analyses supported the efficacy of these therapies for IBS [18,19], but few studies included other FGID. Our combined clinical experience and a growing literature base suggest these therapies may be helpful for specific other FGIDs as well such as functional dyspepsia [20–22]. Despite these overwhelmingly positive findings, psychological therapies are not available to most patients due to lack of GI-trained therapists, low referral rates in the absence of clear psychological distress, and poor insurance coverage for these treatments.

3. Models of integrated care

The benefits of integrated medical and psychological care span the entire treatment course and include reductions in stigma associated with psychological care, improved access, improved communication and collaboration among providers, increased patient satisfaction, and lower overall healthcare costs with improved quality [23,24]. Collaborative team-based care is defined by Choi and Pak [25] as (1) ‘multidisciplinary’, drawing on knowledge from different disciplines but staying within the boundaries of those fields; (2)‘interdisciplinary’, synthesizing disciplines into a coordinated, interactive whole; and (3) ‘transdisciplinary’, transcending discipline boundaries to holistically provide treatment in an integrated new way. Generally speaking, a multidisciplinary treatment setting may offer colocated gastroenterologists and psychologists, whereas an interdisciplinary clinic would include a gastroenterologist and psychologist providing a joint consultation and comprehensive treatment plan to address the biopsychosocial needs of the patient. However, the actual level of care integration is determined by the conceptual approach, rather than the pragmatics of the visit arrangement. Though this review is focused on the integration of medical and psychological care, similar challenges and opportunities likely exist for integration of additional treatment modalities such as nutrition or physical therapy to address illness-associated deconditioning.

Given the biopsychosocial etiology of FGIDs, an interdisciplinary approach that considers interactions between biological and psychological processes, as well as their individual contributions, is likely to be most helpful. However, site-specific needs may dictate how integrated care for patients with FGIDs can be delivered. Practical considerations may include degree of visit integration (e.g., team-based care with medical and psychological providers seeing the patient jointly versus independent visits with joint treatment planning), structure of care provided (e.g., patients are automatically scheduled with all providers versus patients are scheduled depending on team recommendations), and program intensity (e.g. partial or inpatient hospitalization versus outpatient clinics). Some gastroenterology programs also may opt for coordination with a pediatric or health psychologist in the community who has specific training in working with FGID patients. This model can be effective when program structure does not allow coordination with an on-site psychologist due to logistical or financial constraints. However, when integration within a single clinic is not feasible, regular communication between medical and psychological providers regarding ongoing assessment and treatment is paramount.

When resources are limited, some programs may opt for tiered care in which only a subset of patients with FGIDs are referred for psychological treatment and interventions. Providers may wonder when and how to make those referrals. Patients and families willing to consider a biopsychosocial conceptualization of symptoms, experiencing disability and distress related to FGIDs, and patients with comorbid psychological diagnoses (e.g. anxiety, depression) are likely to benefit most from referrals for integrated care. However, we assert that all patients affected by a FGID will benefit maximally from a biopsychosocially-informed treatment plan, as early intervention is likely to disrupt progress toward increased disability and distress, and improve treatment outcomes, even in the absence of pre-existing psychosocial concerns.

The level of patient and/or family acceptance for psychological interventions also may be a factor in referral patterns, as treatment success is likely greater with a higher level of patient acceptance and interest in these treatments. Patients and families who do not recognize that stress or psychological symptoms influence their gastrointestinal symptoms will not likely follow through with treatment or lack the motivation to experience benefit from treatment [26]. Patients may also interpret the suggestion for psychological treatment as a suggestion that their symptoms are ‘all in their heads’. A good explanation of brain–gut interaction, provision of a thoughtful treatment rationale and continued involvement of the GI provider throughout the treatment course are needed (for more in-depth discussion, see Palsson & Whitehead [26]). Provision of sequential care (e.g. medical workup followed by referral to a psychologist without further medical involvement) is typically problematic; this can easily be interpreted in a negative fashion by a patient and/or family, but also fails to meet the definition and goals of integrated care. Further, any potential stigma and patient resistance may be reduced when psychological assessment and treatment is a standard component of medical care for all patients.

4. Getting started and making it work

Physicians can locate appropriate psychological services for patients by recruiting and hiring a psychologist to work within the clinic setting or by identifying resources in the community. Useful resources for finding therapists in the United States and Europe are listed in the following section on therapist referral sources for adults and children. In addition, many university and/or hospital-based clinics have a psychologist on staff who can provide treatment or is aware of local psychologists in the community with specific FGID knowledge and experience. Finally, e-treatments and other telemedicine approaches may need to be considered to expand the availability of psychological therapies in more rural and/or underserved areas. Few e-treatments are currently available and none of these have been tested in rigorous trials. A list of publicly and privately supported clinical trials, including e-treatments currently in development/testing, can be found at ClinicalTrials.gov.

Once a relationship with a psychologist is established, communication and collaboration are primary keys to success. Working with the psychologist partner to come to a shared understanding of FGID assessment and treatment, develop a workable practice model, address potential billing challenges, and develop scripts that can be used with patients and families to communicate the value of psychological therapies as an important component of care, can help make integration a reality. While integrating psychological therapies into traditionally medically oriented care can be challenging, the nature of FGIDs demands a more comprehensive and coordinated approach that can be tailored to the unique practice setting. In the era of pay-for-performance and capitated care models, integrated care for FGIDs has the potential to improve outcomes and save costs if we can find ways to bring effective psychological treatment into the medical home.

5. Therapist referral sources for adults and children

5.1. Cognitive behavioral therapy

• Association for Behavioral and Cognitive Therapies (www.abct.org)

• European Association for Behavioural and Cognitive Therapies (www.eabct.eu)

• Academy of Cognitive Therapy (www.academyofct.org)

• American Board of Professional Psychology (www.abpp.org)

5.2. Hypnosis

• American Society of Clinical Hypnosis (www.asch.net)

• IBS Focused Hypnosis (www.ibshypnosis.com)

• European Society of Hypnosis (esh_hypnosis.edu)

5.3. Biofeedback

• Biofeedback Certification International Alliance (www.bcia.org)

6. Referral lists for children and adolescents

Two referral lists are available with therapists delivering psychological treatments to children/adolescents with GI disorders in the USA. These lists are available through membership in:

• NASPGHAN (https://members.NASPGHAN.org)

• Society of Pediatric Psychology Division 54 Pediatric Gastroenterology Interest Group (http://www.apadivisions.org/division-54/sigs/gastroenterology/index.aspx)

Declaration of interest

M van Tilburg declares research support from Takeda Pharmaceuticals. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded.