How Stress Can Impact Inflammatory Bowel Disease

Author: Hannah J. Moir

Support statement: The writing and publication of this news feature was supported by Viatris, who were not involved in the creation of this content.

INFLAMMATORY BOWEL DISEASE FROM A MIND-BODY PERSPECTIVE

Chronic inflammation of the gastrointestinal tract characterises two conditions collectively referred to as inflammatory bowel disease (IBD), namely Crohn’s disease and ulcerative colitis. These conditions stem from an overactive autoimmune response, coupled with a genetic component, resulting in prolonged inflammation and damage to the gastrointestinal tract.^1,2

Globally, IBD affects approximately 10 million adults.³ Common symptoms include persistent diarrhoea, abdominal pain, rectal bleeding (or bloody stools), weight loss, and fatigue.¹ Treatment options encompass disease-modifying antirheumatic drugs, such as aminosalicylates (5-aminosalicyclic acids); anti-inflammatories, such as corticosteroids; immunomodulators; and biological therapies, such as anti-TNFs.¹ In some cases, surgery may be necessary to remove the damaged portion of the gastrointestinal tract.¹ Those living with IBD can experience periodic flare-ups, even in controlled cases, the cause of which is unknown.²

While researchers have made considerable progress in IBD research, its cause is still unknown. Studies suggest that a complex interaction of factors, including genetics, the immune system, and the environment, contribute to IBD-related inflammation.

Recently, mental health has emerged as a contributing factor to the pathogenesis of IBD.⁴ Those with IBD often experience significant mental health comorbidities, with increasing evidence linking IBD to conditions such as anxiety, depression, and post-traumatic stress disorder.⁵ Psychological factors can worsen disease outcomes and lead to poor quality of life, underscoring the importance of addressing mental health in IBD care.⁶

Presented at the European Crohn’s and Colitis Organisation (ECCO) 2022 Congress, an abstract identified that 72% and 67% of patients (N=192) were suspected to have depression and anxiety, respectively, highlighting the prevalence of mental health issues among those living with IBD.⁶ Furthermore, at the ECCO 2023 Congress, research highlighted that children and young adults aged 5–25 years with IBD (N=3,898) have a significantly higher incidence and risk of new mental health conditions such as depression,⁷ emphasising the critical role of mental health care across all patients with IBD.

Despite its critical role in patient management, mental health remains an often-overlooked aspect of IBD care.

THE BRAIN–GUT AXIS IN INFLAMMATORY BOWEL DISEASE

The brain and the gut are intricately connected and maintain constant communication. Interestingly, the gut contains more neurons than the entire spinal cord. Research published in June 2023 has emphasised the significance of stress and mental in triggering IBD, and has shed light on the role of the enteric nervous system in generating monocyte- and TNF-mediated inflammation of the gut enteric glia through growth factor colony-stimulating factor 1.⁸ The study identified two molecular pathways that link chronic psychological stress to IBD flares.

 The Hormonal Pathway

Psychological stress triggers the release of corticotropin-releasing hormone from the hypothalamus, which stimulates the pituitary gland to release downstream hormones. This cascade ultimately triggers the adrenal cortex to release glucocorticoids, similar to the ‘fight-or-flight’ response. These glucocorticoids reach the gut, where they induce an inflammatory response by acting upon enteric glial cells. These cells turn into enteric cells associated with psychological stress, which release colony-stimulating factor 1 to recruit monocytes to the intestine. These monocytes then signal TNF, causing intestinal cell damage, inflammation and pain associated with IBD.⁸

 The Neurological Pathway

Simultaneously, the stress-induced glucocorticoids stimulate the release of transforming growth factor-β 2 from the enteric neurons. This cytokine reduces neuronal activity, decreases the number of matured neurons, and increases the number of immature neurons. Consequently, the levels of acetylcholine decline, disrupting the signalling pathways that control gut movement. This leads to gut dysmotility, impairing the movement of food through the gut.⁸

While psychological stress may not be the sole cause of IBD, this study highlights that it plays a significant role in the inflammatory response and impaired gut motility associated with the condition.² The research emphasises the potential benefits of targeted stress-management techniques in preventing and treating IBD flares.²

MANAGING STRESS WITH MIND-BODY INTERVENTIONS FOR THOSE LIVING WITH INFLAMMATORY BOWEL DISEASE

To address the stress experienced by those living with IBD, research suggests that patients and healthcare practitioners should actively explore strategies to manage and mitigate stress. Prioritising mental health is critical in the overall management of IBD, necessitating the implementation of mental health screening and support.⁹ Gomez et al.⁵ emphasises the need for multidisciplinary care for those living with IBD, including mental health professionals.

In the current medical landscape, patient-centred care has gained widespread acceptance as the preferred model, particularly for chronic and diverse conditions like IBD. It is imperative to equip healthcare professionals with the skills to assess and address emotional aspects, such as identifying symptoms related to stress, anxiety, and depression, which are prevalent among patients with IBD.

Providing guidance on healthy lifestyle choices should be based on established guidelines for managing stress, recognising that IBD itself can be a source of stress, and stress is considered a risk factor for exacerbating physical symptoms.

Mind–body interventions have shown efficacy in improving symptoms and enhancing quality of life in many chronic illnesses. Mind–body interventions consist of both static and dynamic approaches. Static interventions include cognitive behavioural therapy, meditation, hypnosis, and relaxation therapy. Dynamic interventions engage the body’s joints and muscles through practices such as yoga, tai chi, qigong, and Pilates.

Relaxation techniques, such as mindfulness-based stress reduction exercises, are among the most widely used complementary health techniques. They involve “paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.”¹⁰

Programmes incorporating guided meditations, body scans, sitting meditations, stretching, and breathing exercises, as well as hatha yoga, promote internal awareness, physical alignment, and deep breathing, all of which contribute to stress reduction, increased mindfulness, and enhanced quality of life in IBD.¹¹ Yoga, a holistic practice encompassing physical, mental, and spiritual disciplines aimed at controlling and calming the mind, may be recommended by physicians as a therapeutic option to alleviate IBD-related symptoms.¹²

Offering self-management techniques and complementary approaches, such as yoga, meditation, and relaxation techniques, is likely to yield favourable outcomes in improving patient well-being.

Individuals living with IBD can effectively manage stress through a range of Mind–body interventions. Embracing patient-centred care and addressing mental health concerns are pivotal steps in enhancing quality of life for these patients. Healthcare practitioners can play a vital role in guiding patients with IBD towards resources and interventions that promote stress management and overall well-being.

References

1. Centers for Disease Control and Prevention (CDC). What is inflammatory bowel disease (IBD)? 2022. Available at: https://www.cdc.gov/ibd/what-is-IBD.htm. Last accessed: 21 September 2023.
2. Fischman J. See how stress affects inflammatory bowel disease. 2023. Available at: https://www.scientificamerican.com/article/see-how-stress-affects-inflammatory-bowel-disease/. Last accessed: 21 September 2023.
3. European Federation of Crohn’s and Ulcerative Colitis Associations (EFCCA). What is IBD? 2023. Available at: https://efcca.org/content/what-ibd. Last accessed: 21 September 2023.
4. Barberio et al. Prevalence of symptoms of anxiety and depression in patients with inflammatory bowel disease: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2021;6(5):359-70.
5. Gomez DA et al. IBD-related mental health disorders: where do we go from here?. Frontline Gastroenterology. 2023;DOI:10.1136/flgastro-2023-102403.
6. Banerjee R et al. P227 High prevalence of mental health illness in IBD patients with high caregiver burden in the developing world: An analysis of risk factors from the IBD Emerging Nations Consortium (IBD-ENC). J Crohns Colitis. 2022;16(Suppl 1):i276-7.
7. Cooney R et al. OP28 Children and young adults with inflammatory bowel disease have an increased incidence and risk of developing mental health conditions: a UK population-based cohort study. J Chrons Colitis. 2023;17(Suppl 1):i39-40.
8. Schneider KM et al. The enteric nervous system relays psychological stress to intestinal inflammation. Cell. 2023;186(13):2823-38.e20.
9. Fiorino G et al. ‘Quality of care’ standards in inflammatory bowel disease: a systematic review. J Crohns Colitis. 2019;13(1):127-37.
10. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol. 2003;10(2);144-56.
11. Naude C et al. The effectiveness of mindfulness-based interventions in inflammatory bowel disease: as systematic review and meta-analysis. J Psychosom Res. 2023;169:111232.
12. Kaur S et al. Yoga in patients with inflammatory bowel disease: a narrative review. Crohns Colitis 360. 2022;4(2):otac014.