PSYCHOLOGICAL ASPECTS OF

GASTROINTESTINAL DISORDER
dr. Irmia Kusumadewi, SpKJ(K)/ dr Sylvia D. Elvira, SpKJ (K)
Divisi Consultation Liason Psychiatry
Department of Psychiatry RSCM/FMUI
 INTRODUCTION

• Terms: gastrointestinal functional symptoms or functional

gastrointestinal disorder or somatic symptom disorder
• Prevalence: 10%-20%
• Examples of complaints or diseases:
• Dyspepsia, constipation, diarrhoea, and abdominal pain
• Gastroesophageal reflux (GERD), peptic ulcer, Irritable
Bowel Syndrome (IBS), Inflammatory Bowel Disease (IBD)
Sobański et al, 2015; Jones et al, 2007
 TWO SIDES OF THE STORIES

1. “Absence of organic disease”  turn to a number of

experts in search for verification and confirmation of the
diagnosis of somatic disease  doctor shopping
2. Confirmation of organic disease  psychological factors
are often omitted  amplification of somatosensory
perception  delayed recovery

Sobański et al, 2015

 “ABSENCE OF ORGANIC DISEASE”

• DSM V  Somatic symptom and related disorders

• Emphasizes on the basis of positive symptoms and signs
(distressing somatic symptoms plus abnormal thoughts, feelings,
and behaviors in response to these symptoms)
• Prominent focus on somatic concerns and their initial
presentation mainly in medical rather than mental health care
settings
DSM V, 2013
FACTORS CONTRIBUTING THE SOMATIC SYMPTOM
AND RELATED DISORDERS

1. Genetic and biological vulnerability (e.g., increased sensitivity to

pain)
2. Early traumatic experiences (e.g., violence, abuse, deprivation)
3. Learning (e.g., attention obtained from illness, lack of
reinforcement of nonsomatic expressions of distress)
4. Cultural/social norms that devalue and stigmatize psychological
suffering as compared with physical suffering
DSM V, 2013
DSM V, 2013
DSM V, 2013
“CONFIRMATION OF ORGANIC DISEASE”

• Non-functional:

• Gastroesophageal reflux (GERD)

• Peptic ulcer
• Chronic Gastritis
• Inflammatory Bowel Disease (IBD)
• Functional:

• Irritable Bowel Syndrome (IBS)

• Functional Dyspepsia
DSM V, 2013
PSYCHOLOGICAL FACTORS AND GI PROBLEMS

• It is generally accepted that psychological factors

influence the course of the disease, including its
severity and frequency of exacerbations.
• Effective treatment requires an understanding of the
psychosocial background against which symptoms
occur.

Sobański et al, 2015; Jones et al, 2007

PSYCHOLOGICAL FACTORS ASSOCIATED WITH
GASTROINTESTINAL DISORDERS AND DISCOMFORT

• Current burdensome life events • Personality and coping

or life stress strategies
• Abnormal relationships with • Inadequate social support
parents • Comorbidities: anxiety
• Abuse disorder, depression
• Neuroticism

Sobański et al, 2015; Jones et al, 2007

 HOW DOES GASTROINTESTINAL AND
PSYCHOLOGICAL COMPLAINTS RELATE?
 GUT – BRAIN AXIS

• Communicate in a bidirectional fashion, largely through the

autonomic nervous system (ANS) and hypothalamic pituitary-adrenal
(HPA) axis.
• Within the CNS, the locus of gut control is chiefly within the limbic
system, which is responsible for both the internal and external
homeostasis of the organism.
• The limbic system also plays a central role.

Jones et al, 2007

 THE BRAIN-GUT AXIS

• Bidirectional communication between brain and gut

• Complex system including endocrine, immune and
humoral links
• Vagus nerve is a neural component of this network
• Gut microbiota have an important impact
• Essential for gastrointestinal homeostasis and the
connection of emotional and cognitive brain areas
with peripheral intestinal functions
• Therapeutic target for several disorders
THE LIMBIC SYSTEM IN
THE GUT – BRAIN AXIS

• Emotionality (survival, threat-avoidance, social

interaction, and learning “mind/body interaction”
• “Top-down” modulation of visceral pain and visceral
perception  cognitive/psychological factors, visceral
perception, and motor abnormalities

Jones et al, 2007

THE ROLE OF SEROTONIN (5-HT)

• The activation and inhibition of pain pathways and the initiation of

the peristaltic reflex
• 5-HT  enterochromaffin cells in the mucosal crypts and within
the nerve fibers of the myenteric and submucosal plexuses
• Primary receptors: 5-HT3 and 5-HT4
• Enteric nerves or on GI smooth-muscle cells: 5-HT1A, 5-
HT1C, 5-HT1P, and 5-HT2.

Jones et al, 2007

 5-HT AND TREATMENT

• Altered levels of 5-HT  generalized anxiety, obsessive-compulsive

disorder, phobias, major depressive disorders  altering sleep 
antidepressant
• Blockade of serotonin and norepinephrine in the enteric nervous
system may function to reduce transmission of messages to pain
centers and thereby re-establish normal brain-gut connections.

Jones et al, 2007

BIO-PSYCHO-SOCIAL MODEL

Jones et al, 2007

EFFECTS OF DIFFERENT EMOTIONS
ON THE GASTROINTERSTINAL TRACT

Wilhelmsen, 2000
WHAT SHOULD WE DO?
IMPLEMENTING PSYCHIATRIC
SCREENING IN CLINICAL PRACTICE
• In general, gastroenterologists and primary-care
physicians are both poorly trained and motivated to
undertake effective psychosocial screening.
• Instruments that can be used:
HAM-A, HAM-D, MADRS, Perceived Stress Scale

Jones et al, 2007

 THERAPY

• Psychotherapy  “effective in reducing symptoms compared with a pooled

group of control conditions.”
• Types: Psychoeducation, Cognitive Behavioral Therapy, Hypnotherapy,
Relaxation Therapy
• Prognostic factors: younger age, type of pain, and higher initial anxiety
• Pharmacotherapy  antidepressants
• Selective Serotonin Reuptake Inhibitors, Tricyclic Antidepressant

Jones et al, 2007; Wilhelmsen, 2000; North et al, 2007

CONCLUSION

• Bidirectional communication between brain and gut

• Complex system including endocrine, immune and humoral links
• Imbalance of neurotransmitters can cause gastrointestinal disorders, as
IBS as well depression
• Antidepressant and psychotherapy has important roles in treating
functional dyspepsia
 REFERENCES

• Sobański JA, Klasa K, Mielimąka M, et al. The crossroads of gastroenterology and psychiatry – what benefits
can psychiatry provide for the treatment of patients suffering from gastrointestinal symptoms. Przegla̜ d
Gastroenterologiczny 2015;10(4):222-8.
• Jones MP, Crowell MD, Olden KW, Creed F. Functional gastrointestinal disorders: An update for the
psychiatrist. Psychosomatics 2007;48:93-102.
• Wilhelmsen I. The role of psychological factors in gastrointestinal disorders. BMJ Journals 2000;47(4):iv73-5.
• North CS, Hong BA, Alpers DH. Relationship of functional gastrointestinal disorders and psychiatric
disorders: Implications for treatment. World J Gastroenterol 2007;13(14):2020-7.
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Washington, DC: American Psychiatric Association; 2013.
THANK YOU
Any questions?
You can find me at
sylvia.d.elvira@gmail.com
sylvia.Elvira@ui.ac.id