“If a patient’s anxiety is not addressed in the context of the IBD patient’s story and their care, it will impact their disease outcomes,” Laurie Keefer, PhD, emphasized at her session at Digestive Disease Week 2022, on May 22 in San Diego, California.

Dr Keefer is a professor of medicine and a gastrointestinal health psychologist at the Icahn School of Medicine at Mt. Sinai in New York City.

Dr Keefer pointed out the “concept that anxiety occurs on a spectrum,” explaining that individuals may experience productive anxiety, anxiety symptoms, or anxiety disorders. The anxiety disorder presents when a patient is “unable to control feelings of unease, worry or fear.”

She noted that about 1 in 3 patients with IBD will meet criteria for some kind of anxiety — “either a disorder or symptoms.” She also described the problem of defining or measuring anxiety, stating that “it’s really, really hard to capture the actual global burden of that anxiety.”

Anxiety in patients with IBD can manifest as several different types: social anxiety and fear of embarrassment; symptom-specific anxiety associated with feeling pain or urgency; food-related anxiety; procedure-related anxiety/phobia; and generalized anxiety and worry, which “is the most common thing. When many of us refer to IBD anxiety, we talk about worry.”

Worry about health is twice as common among patients with IBD than in the general population. This anxiety is often accompanied by trouble sleeping, concentrating, and decision making, as well as physical manifestations such as muscle tension and headaches. For IBD patients, Keefer pointed out that generalized anxiety “may really focus around their disease…you may see your patient perseverating on whether they’re going to need surgery, or an ostomy, whether their biology is going to cause them cancer, whether they’re going to pass their IBD onto their children.” Worry about health can interfere with a patient’s care and impact treatment decision-making, doctor-patient relationship, and quality of life, and may result in behavior inhibition which Dr Keefer described as “when a person is afraid to take action, so they don’t take any action.”

Risk factors for the development of anxiety include the female sex—although Dr Keefer mentioned that could be debated—being 40 years of age or older, active disease, and a recent surgery or hospitalization.

Anxiety can manifest in sign and symptoms across the systems of a patient. There may be experiences of hot flashes or chills, trembling, difficulty breathing, nausea or abdominal distress, dizziness, muscle tension, persistent irritability, and many others. “It’s not so simple,” Dr Keefer stressed, “to just look at anxiety in the emotional way that we tend to think of it. You’re going to see it clinically, in your practice, as symptoms that potentially affect your treatment.”

There are several tools to measure anxiety. Dr Keefer highlighted the National Institute for Health Patient-Reported Outcomes Measurement Information System with a selection for mental health and anxiety and fear, the Hospital Anxiety and Depression Scale, and the Generalized Anxiety Disorder-7. There is also option of simply starting a discussion with your patient. Dr Keefer advised, “Why don’t you just ask your patients what kinds of concerns they have, or what worries them, what makes them anxious, how they’re feeling physiologically, to have that conversation instead of relying on one specific tool.”

Dr Keefer emphasized that “patients have to heal both physically in their guts, but also emotionally to really be considered well.”

Dr Keefer explained that anxiety can create disease-management interfering behaviors, or “behaviors by the patient (or provider) that get in the way of an optimal medical or surgical outcome.” Some causes of these behaviors within patients are increased threat expectancy, disrupted expected value calculation, heightened reactivity to uncertainty, behavior/cognitive avoidance, deficient safety learning, and increased attention/vigilance.

Addressing avoidance, Dr Keefer stated, is the key to anxiety reduction. Cognitive behavior therapy with exposure-based exercises, which are well established outside of the GI realm, show that “forcing people to put in the work to face their fears” is useful. “Anxiety is often best managed,” she stated, “by helping support our patients to face their fears, rather than avoid them.”

—Allison Casey

Reference:
Keefer L. A deep dive into manifestations of anxiety in IBD. Presented at: Digestive Disease Week; May 22, 2022. San Diego, California.