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Jacklyn Stellway, PsyD & Ciera Korte, PhD

09/17/2024

OHSU

IBS and symptom-specific anxiety

Pediatric developmental/behavioral pediatric ECHO – Ukraine

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Objectives

Review disorders of gut brain interaction (DGBI) and common cognitive and behavioral issues
Identify the overlap of Irritable Bowel Syndrome (IBS) and anxiety
Approaches to symptom-specific anxiety

For the medical provider
For the behavioral health specialist

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Disorders of Gut-Brain Interaction

Formerly known as “Functional Gastrointestinal Disorders” (FGID)
Symptom-based criteria

Include Functional Abdominal Pain Disorders (FAPDs)
Functional Dyspepsia
Functional Abdominal Pain NOS (FAP)
Abdominal Migraine

Irritable Bowel Syndrome (IBS)

Upper or lower abdominal pain once weekly or more
Duration 2 months or longer
At least sometimes relief with defecation and change in stool form/frequency
Types

Constipation (IBS-C)
Diarrhea (IBS-D)
Mixed (IBS-M)

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(Schmulson et al, 2017)

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Disorders of gut-brain interaction (DGBI), formerly known as functional gastrointestinal disorders are a group of medical conditions involving problems in communication between the gut and brain.

The exact cause of DGBI is not fully understood, but a diagnosis can be confidently made using symptom-specific criteria and rule out of other identifiable organic etiology.

DGBI present with variety of symptom including:

abdominal pain

bloating

constipation

diarrhea

nausea

Symptoms are used to classify DGBI into various subdomains, such as functional abdominal pain disorders which are common in pediatric populations. Functional abdominal pain disorders include functional dyspepsia, functional abdominal pain not otherwise specified, abdominal migraine, and irritable bowel syndrome or IBS.

IBS is characterized by upper or lower abdominal pain occurring at least once a week for a duration of at least two months. Patients with IBS present with change in stool form or frequency such as constipation or diarrhea or a combination of both. Symptom relief often follows defecation.

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Biopsychosocial Model

(Drossman & Ruddy, 2020)

Social

Culture

Social Support

Parental behaviors

Environment

Trauma

Biological

Genetics

Motility

Inflammation

Altered Microflora

Food/diet

Psychological

Personality/Temper

Emotional state

Hypervisceral sensitivity

Hypervigilance

Coping/Cognition

Behaviors

Presentation

Symptoms

Severity

Comorbidity

Behaviors

Outcomes

Healthcare Use

Daily function

Quality of life

Healthcare cost

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Biopsychosocial Factors

Cognitive Processes

Passive coping

Obsessive thoughts

Low self efficacy

Hypervigilance

Symptom specific anxiety

Visceral hypersensitivity

Emotions

Stress

Anxiety

Fear

Shame

Social Interaction

Social events

Family stress

Family dynamics

Parenting style

Early Development

Attachment

Temperament

Behaviors

Inactivity

Avoidance/withdrawal

Disrupted sleep

Genetics

Biological predisposition

Environment

Infection

Allergies

Trauma

Medication

Alter gut microbiome

Diet

Food intolerance

Food intake

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Maintenance of IBS: Visceral Hypersensitivity

Medical Events

Distention

Inflammation

Motility Disorder

Pain Signals

Perception

Pain!

I’ve seen this before…

Fryefield (2021), Simons (2020)

Warning Signals

Pain Signals

Sensitizing Psychosocial Events

Depression, Anxiety/Fear, Stress

Family Stress

Coping Style

Secondary Gains

Abuse

Changes in Pain Processing

Hypervisceral Sensitivity

Hypervigilance

Increased functional impairment

Fear Avoidance Model (FAM) of Pain

neutral stimuli often become associated with distressing symptoms, leading to life-limiting avoidance
chronic pain is maintained by pain catastrophizing and avoidance which persist despite physical healing, increasing pain sensitivity

Important to consider realistic fear versus excessive fear in the context of symptoms

Visceral hypersensitivity plays a key role in the development and maintenance of symptom-specific anxiety. The process begins with a real physiological symptom that represents a medical event. For example, uncomfortable distention, inflammation, or constipation.

This even causes pain signals to be sent to the brain. Contextual factors such a low mood, anxiety, stress, or fear of repeated symptoms amplify the experience of real physical pain and discomfort by altering perception.

Over time, this leads to hypervisceral sensitivity and increased hypervigilance and impairment as abdominal pain signals are send to the brain which increases arousal, thereby increasing GI discomfort.

The fear avoidance model of pain explains how neutral stimuli, such as normal GI processes such as digestion or motility, become associated associated with upsetting symptoms. This triggers avoidance and fear that often persist despite physical healing. For example, children may start to avoid places in which they have experienced embarrassing symptoms. Avoidance can be reinforced by reduced fear and relief, demonstrating the impact of classical and operant conditioning.

It is critical to fear of realistic threat (such as not having access to a bathroom when one has diarrhea) versus unnecessary fear that becomes life-limiting.

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Symptom-specific anxiety

Visceral Sensitivity Index

Trieschmann et al., 2022

WORRY

FEAR

VIGILANCE

SENSITIVITY

AVOIDANCE

Obsessive thoughts

Catastrophizing

Negative thoughts

Future-oriented

Learned behavior

Classical conditioning

Negative associations

Increased attention

Awareness

Looking for danger

Hyper-focused

Heightened Perception

GI-specific sensations

Eating, stress, etc.

Safety behaviors

Rituals

Seek reassurance

The visceral sensitivity index was developed to help assess these processes in youth with IBD. There are 5 dimensions of GI-specific anxiety which include:

1) Worry: obsessive, negative, catastrophic thoughts, either learned or innate, reflecting a negative, future oriented perspective on GI symptoms.

2) Fear: learned responses to previously innocuous physical sensation(s) that have been paired with a painful or aversive stimulus; often unassociated with feelings of anxiety.

3) Vigilance: an increased awareness of attention to, and increased relevance of GI-specific sensations resulting in a decreased ability to attend to other internal or external stimuli.

4) Sensitivity: Heightened perception of GI-specific sensations and symptoms under a variety of conditions, including eating and stress.

5) Avoidance: Increased safety behaviors, rituals, and seeking reassurance to GI-specific sensations.

https://onlinelibrary.wiley.com/doi/abs/10.1111/nmo.14384?casa_token=GeGmeXYDPMUAAAAA%3A6laDWkF1DYyvvhpd_nVzMUDAszrvnmd6-z9hxoxGUN7IG5wA6umY13KbX0Qao9GjSIMhpgHAu6TqpA

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Overview of DGBI Treatment

Patient-Provider Relationship

Education

Individualized

Brain-behavior therapies

Pharmacologic

Nutrition

Lifestyle changes – exercise, sleep

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Brain-behavior therapies�

(Ballou & Keefer, 2017)

Thoughts

“people might notice if I’m in the bathroom too long at the party”

Behaviors

Avoid eating at the party in order to avoid needing the bathroom

Emotions

Anxiety

Embarrassment

Shame

Physical Sensations

Stomach pain

Tightness in abdomen

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Addressing symptom-specific anxiety:�for the medical provider

Behaviors

Health behaviors

Activity pacing – school notes

Parent behavior

Assessment of avoidance

Medical Management

Neuromodulators to downregulate the nervous system (stigma*)

Histamine H1 receptor antagonists

Illness Education

Gut brain axis

Fluctuations vs Flags

Hurt ≠ Harm

Ongaro et al., 2023

Miranda, 2022

Farzaei et al., 2016

Lamparyk et al., 2023

Alleviate discomfort

Reduce functional impairment

Obtain buy-in, develop shared understanding

Recommendations for a medical provider to educate on, and encourage/recommend during their visits…include

Education about the gut-brain axis and helping patients and families develop a plan for when to reach out for medical support (i.e. “flags”) versus what symptoms can be anticipated as a normal course of IBS (i.e. “fluctuations”). It is important for families to understand that despite the brain’s sensitization to pain, hurt does not always mean harm is occurring.

Neuromodulators help decrease the strength of unhelpful gut-brain communication that is not signaling harm. However, because many of these medications are antidepressants they may carry stigma. Educating families on why these medications are being prescribed helps avoid sending the message ”this is all in your head” which many patients may feel due to the lack of a clear etiology of DGBI.

Providers can also help support in encouraging health behaviors and reducing excessive parent accommodation or fear that can perpetuate symptoms by giving accurate education and setting goals. Additionally, school notes advocating for increased access to the bathroom during sports or class can help keep kids engaged in daily activity.

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Addressing symptom-specific anxiety:�for the behavioral health provider

Targeting Thoughts

Cognitive Restructuring

Coping Thoughts

Defusion

Behavior Change

Activity Pacing

Behavioral Experiments

Graduated Exposure

Incentives/Motivation

Calming the Nervous System

Diaphragmatic Breathing

Progressive Muscle Relaxation

Mindfulness

Grounding

Korte & Friedberg, 2021

Reduce functional impairment

Alleviate emotional suffering and change self-limiting beliefs

Decrease physiological arousal and increase self-efficacy

For the behavioral health provider, calming the nervous system is often the first goal of treatment. Relaxation strategies such as diaphragmatic breathing, progressive muscle relaxation, and mindfulness can reduce stress along the gut-brain axis. Communicating these interventions as strategies to impact physiological functioning helps validate the physical symptoms that patients with DGBI are experiencing.

Activity pacing or graduated exposure can help children reduce unnecessary avoidance that often results from learned fear. Utilizing agreed upon rewards to gradually experiment with new activities can help motivate children to engage in feared activities.

Finally, challenging catastrophic thoughts about GI symptoms (e.g., everyone must be wondering why I was in the bathroom for so long), identifying helpful thoughts (e.g., my pain is real but is not harming my body), or creating distance between a thought and emotional reaction though the process of defusion can help alleviate emotional suffering and challenge self-limiting beliefs.

Due to the nature of DGBI, it is essential that treatment addresses the complex nature of the gut brain axis while validating the lived experience and challenges of children with these medical diagnoses.

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Thank You