Sharon Jedel

A Randomized Controlled Trial of Mindfulness-Based Stress Reduction to Prevent Flare-Up in Patients with Inactive Ulcerative Colitis

Background/Aims: The primary therapeutic goals in ulcerative colitis (UC) are to maintain excellent quality of life (QOL) by treating flare-ups when they occur, and preventing flare-ups. Since stress can trigger UC flare-ups, we investigated the efficacy of mindfulness-based stress reduction (MBSR) to reduce flare-ups and improve QOL. Methods: Patients with moderately severe UC, in remission, were randomized to MBSR or time/attention control. Primary outcome was disease status. Secondary outcomes were changes in markers of inflammation and disease activity, markers of stress and psychological assessments. Results: 55 subjects were randomized. Absence of flares, time to flare and severity of flare over 1 year were similar between the two groups. However, post hoc analysis showed that MBSR decreased the proportion of participants with at least one flare-up among those with top tertile urinary cortisol and baseline perceived stress (30 vs. 70%; p < 0.001). MBSR patients who flared demonstrated significantly lower stress at the last visit compared to flared patients in the control group (p = 0.04). Furthermore, MBSR prevented a drop in the Inflammatory Bowel Disease Quality of Life Questionnaire during flare (p < 0.01). Conclusion: MBSR did not affect the rate or severity of flare-ups in UC patients in remission. However, MBSR might be effective for those with high stress reactivity (high perceived stress and urinary cortisol) during remission. MBSR appears to improve QOL in UC patients by minimizing the negative impact of flare-ups on QOL. Further studies are needed to identify a subset of patients for whom MBSR could alter disease course.

The relationship between coping, health competence and patient participation among patients with inactive inflammatory bowel disease

BACKGROUND Coping is an integral part of adjustment for patients with Inflammatory Bowel Disease but has not been well described in the literature. This study explored the relationship between coping, perceived health competence, patient preference for involvement in their treatment, depression and quality of life, particularly among patients with inactive disease (in remission). METHODS Subjects (n=70) with active and inactive IBD completed questionnaires, including the Inflammatory Bowel Disease Quality of Life Questionnaire, Beck Depression Inventory, Perceived Health Competence Scale and the Coping Inventory for Stressful Situations. The Harvey Bradshaw Index measured disease activity. RESULTS Patients with inactive IBD demonstrated significantly more interest in participating in their treatment (p<.05), more perceived health competence (p=.001), less depressive symptoms (p<.001), more task oriented coping (p=.02), and better quality of life than those with active disease. Only Task Oriented Coping was significantly negatively associated with the number of flares among inactive patients (p<.001). Patient preference for participation in treatment was inversely associated with Avoidance (p=.005), Distraction (p=.008), and Social Diversion (p=.008) coping among inactive patients. CONCLUSION Among patients in remission, those who expressed a greater interest in treatment participation were also less likely to practice maladaptive coping. Our data demonstrate that a more active coping style may be associated with improved health outcome. Compared to patients with active disease, patients in remission are more likely to employ task oriented coping, demonstrate a higher interest in treatment participation, report greater perceived control of their health, and exhibit less depression symptoms. Our findings may increase awareness of the importance of identifying coping strategies for IBD patients, including those in remission.

Getting personal: a review of sexual functioning, body image, and their impact on quality of life in patients with inflammatory bowel disease.

Background:Inflammatory bowel disease (IBD), which includes Crohns disease and ulcerative colitis, is a chronic relapsing disorder associated with distressing physical and psychological symptoms. Many patients with IBD have impaired quality of life. Sexual functioning and body image are rated high among concerns of patients with IBD and may impact quality of life. A better understanding of the roles of sexual functioning and body image in quality of life for patients with IBD is needed because improvement in quality of life is a primary therapeutic goal. The aim of this review was to summarize the current literature on sexual functioning and body image in patients with IBD, emphasizing their impact on quality of life. Methods:An electronic search of the literature was conducted using the PubMed, PsycINFO, and Cochrane databases. Key phrases included: “Ulcerative Colitis/Crohns disease/Inflammatory Bowel Disease and sexual function,” and “Ulcerative Colitis/Crohns disease/Inflammatory Bowel Disease and body image.” The search produced 1284 citations. We identified 56 studies, which were conducted from 1990 through April 2014, written in English, and included at least 10 adults with IBD. Conclusions:Few studies have tested directly the association between quality of life and sexual functioning and body image among patients with IBD. Results preliminarily suggest a positive relationship between quality of life and sexual functioning and body image postoperatively among patients with IBD. Future studies comprised of patients who have not had surgery are necessary to better understand the relationship between sexual functioning, body image, and quality of life in patients with active and inactive IBD.

Mindfulness-Based Interventions in Inflammatory Bowel Disease

Mindfulness-based interventions may be beneficial psychosocial treatments for improving the health and well-being of patients with inflammatory bowel disease. This article reviews eight studies, assessing seven psychosocial interventions, which include mindfulness and/or meditation components. Strongest effects of the interventions were found in quality of life and anxiety/depression, with inconsistent or minimal changes in other psychosocial areas, such as perceived stress and in disease-related outcomes and other physiologic functioning. Mindfulness interventions for patients with inflammatory bowel disease may be a supplemental treatment option to improve quality of life and distress in this population, although results are preliminary and interventions require additional testing.

Addressing the Mind, Body, and Spirit in a Gastrointestinal Practice for Inflammatory Bowel Disease Patients

The past decade has witnessed a growing emphasis on the importance and clinical relevance of incorporating a multidisciplinary approach to address patients’ priorities and desires that includes specific attention to mind–body approaches in the treatment of many gastrointestinal (GI) illnesses. This trend may be attributed to mounting empiric evidence indicating that the disease course and even etiology of many functional and organic GI illnesses is best understood by a combination of genetic, physical, physiological, and psychological factors. There also has been increased recognition of the pervasive, psychosocial impact that chronic GI illness may have on the patient’s life and disease course, as well as the benefits of addressing such issues in management of these disorders.1,2 It is thus paradoxic that gastroenterology practices in teaching hospitals and private practices rarely incorporate interventions to address the interaction of mind and body in the treatment of their patients. However, many GI patients often seek to either supplement or even substitute their standard care with alternative approaches. This desire results from dissatisfaction with standard therapies, negative side effects of conventional medication, and/or an attempt to avoid medication and a desire for a greater sense of control over one’s health.3 Simply put, patients seem to prefer a holistic approach, one that considers not merely the body’s specific physical symptoms, but the illness experience in its entirety: mind, body, and spirit. Stress is one of the most important environmental factors that impacts mind, body, and spirit. Although the specific mechanisms by which stress affects the gut are largely unknown, evidence suggests that stress affects GI function through several mechanisms, including activation of the brain-gut axis and modulation of hormonal and neuroimmune pathways.4-6 For example, the stress hormone corticotrophin-releasing factor is involved in the endocrine, behavior, and visceral responses to stress including stress-induced changes in GI motility and intestinal mucosal barrier function. Stress reactivates and exacerbates colonic inflammation in experimental colitis and increases mucosal inflammatory markers in inactive ulcerative colitis (UC) patients by activating mucosal mast cells and disrupting mucosal barrier integrity.4,6 Perceived stress predicts mucosal abnormalities among UC patients,7 an effect that may be caused by stress-induced exacerbation of mucosal inflammatory cascades. These studies provide substantial evidence that stress influences the GI tract and bolsters support for the impact of the long-lasting effects of stress on GI function that could impact the disease course in illnesses such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). Despite compelling experimental data that stress and the mind impact wide ranges of GI functioning and the inflammatory cascade, we still await future studies to see if stress management and holistic therapeutic approaches could indeed impact the disease course of GI illnesses. However, recent studies have suggested that these interventions positively impact patients’ quality of life by at least improving their coping and associated symptoms of depression and anxiety, which are extremely common in patients with IBD and IBS.2 Indeed, mounting evidence suggests that psychotherapy can have a significant impact on both psychological and clinical outcomes measures. Psychotherapy for IBD patients typically has incorporated relaxation and stress management techniques, and selected interventions are based on various theoretic orientations, including psychoanalysis and psychodynamic theory, cognitive behavioral theory, and supportive psychotherapy.2 Most clinicians are keenly aware that coping with a chronic illness, such as IBD and IBS, can be extremely challenging, with a major negative impact on the patient’s quality of life. These patients worry regularly about the numerous uncertainties associated with their disease, such as when the next flare will occur, whether they can control their urge to defecate during social events or at work, whether current medications will cease to be effective, and whether surgery will become necessary. These concerns also impact their interactions with family members, children, coworkers, and friends, resulting in increased difficulties in coping with their disease and contributing to mood disturbances. It is not surprising that IBD patients suffer from symptoms of depression and anxiety as high as 60% to 80% during flare-ups and even up to 35% during remission.8 Interventions helping these patients to confront these difficulties by either exploring their feelings through psychotherapy, or by increasing their awareness of feelings through techniques such as Mindfulness-Based Stress Reduction (MBSR), could improve their illness coping, and this should lead to improved quality of life. Indeed, our recent, unpublished data of 50 patients with ulcerative colitis showed that mindfulness (as measured by the Mindfulness Attention and Awareness Scale9) showed a significant positive correlation with quality of life (rs = 0.49; P < .01). Further studies are needed to show whether these techniques indeed would impact these patients’ lives positively. Nonetheless, the following 2 vignettes show how IBD-specific individual and group psychotherapy as well as MBSR potentially could be useful in the management of a subset of IBD patients; thus practicing gastroenterologists should identify patients with poor coping and comorbid anxiety/depression who could benefit from such interventions.

Are Male Disaster Workers With Vietnam Military Service at Greater Risk for PTSD Than Peers Without Combat History

This study examined whether male disaster workers with Vietnam service histories were at risk for posttraumatic stress disorder when compared with colleagues following duties at Ground Zero. The study compared participants from ongoing psychiatric screening of disaster workers: those with Vietnam service (Vietnam veteran; N = 125), those without trauma history (no trauma; N = 116); and those with childhood physical abuse but no combat history (physical abuse; N = 57). ANOVA indicated the trauma groups differed significantly in clinician-rated posttraumatic stress disorder severity (p < 0.005). However, post hoc analyses revealed the Vietnam veteran group did not differ significantly from the no trauma group; both had significantly lower severity compared with the physical abuse group. It should be noted that veterans in this sample, unlike in many studies, were in the workforce. Research with different veteran groups is warranted to clarify further the relation of combat experience and symptoms in disaster workers.

Sleep Quality in Ulcerative Colitis: Associations with Inflammation, Psychological Distress, and Quality of Life

PurposeTreatment of ulcerative colitis (UC), given its chronicity and its associated disruptive and often distressing symptoms, is increasingly focusing on maximizing patient quality of life. Poorer quality of life has been found among patients with poor sleep quality, which is much more common in patients with UC than in the general population and may be associated with inflammation and psychological distress.MethodForty-seven patients with UC (n = 11 flaring) completed measures of sleep quality, depression, state anxiety, gastrointestinal-related anxiety, perceived stress, and quality of life. Measures of inflammation were also obtained.ResultsPatients endorsed high rates of poor sleep quality, which was highly correlated with depression and poorer inflammatory bowel disease-related quality of life, but was generally not related to other areas of psychological functioning or inflammation. Sleep quality was significantly independently associated with depression and female gender.ConclusionPoor sleep quality is prevalent in patients with UC and is strongly related to depression, suggesting that sleep and mood are important areas to assess in patients with UC in order to inform tailored treatment to improve quality of life.

Su1283 Biopsychological Markers Predict Ulcerative Colitis Disease Flare-Up

Introduction: Ulcerative colitis (UC), one of the two main types of chronic Inflammatory Bowel Disease (IBD), is a significant health problem that is characterized by symptomatic periods (flare-up) interspersed with asymptomatic periods (remission). Since there is no cure for UC, the therapeutic goal is to prevent flare-ups and promptly treat them when they occur. Identifying biological and psychological markers that predict flare-up would significantly improve the management of UC by optimizing treatment to prevent flare-up. The aim of this study was to objectively define biopsychomarkers that predict UC flare-up. Methods: 54 UC patients in remission were included in this prospective longitudinal study. UC patients had at least one documented flare-up within the past 12 months and were either taking no IBD medication or were on a stable dose of IBD medication for at least three months prior to enrollment. Baseline information collected included: markers of inflammation and UC disease activity (i.e., stool calprotectin, serum CRP, serum cytokines, UC disease activity index, sigmoidoscopy score, histological score), sigmoid mucosal microarray analysis for mRNA of genes of interest (i.e., 70 genes), markers of stress (i.e., fasting serum ACTH, 24h urinary cortisol, PSQ), quality of life measure (IBDQ), and psychological assessments (i.e., BDI, STAI, MAAS, PHCS). Flare-up was defined as Mayo UC-DAI >2 plus rectal bleeding score ≥2 and sigmoidoscopy score of ≥2. Results: Twenty seven out of 54 UC subjects (50%) flared over a 12-month period. None of the psychological assessments or markers of stress were significant predictors of UC flare-up. Nor were stool calprotectin or serum C-reactive protein (CRP), ACTH, TNFα, or IL10 predictive of flare-up. However, endoscopy score (grade 1), serum IL6, and serum IL8 were significantly different between UC patients with and without flare-up. Analysis of gene expression in mucosal biopsy found eight genes predictive of UC flare-up including inflammatory (IL23R, STAT3, HMGB1), stress (CRHR2), brain-gut axis (NPY), intestinal barrier (TJP1), as well as other (TP53, LRRK2) genes. Furthermore, expression of HMGB1, OCLN (intestinal barrier), and TP53 predicted whether flare-up occurred within 6 or 12 months. Conclusion: Our prospective study found that: (1) stool calprotectin, serum TNFα, ACTH, IL10, urine cortisol, histological score, and psychological measures at baseline did not predict UC flare-up; (2) high serum IL6, low serum IL8, and grade 1 endoscopy score (i.e., loss of vascular pattern) at baseline predicted UC flare-up during the following 12 months; and (3) a characteristic mucosal gene signature predicted early (i.e., within six months) and late (i.e., within 12 months) UC flare-up.

Tu1279 Relationship Between Beliefs in Complementary and Alternative Medicine and Psychosocial Variables Among IBD Patients

Improving Case Definition of Crohns Disease and Ulcerative Colitis in Electronic Medical Records Using Natural Language Processing − a Novel Informatics Approach Ashwin N. Ananthakrishnan, Tianxi Cai, Su-Chun Cheng, Pei Jun Chen, Guergana Savova, Raul Guzman Perez, Vivian S. Gainer, Shawn N. Murphy, Peter Szolovits, Katherine Liao, Elizabeth W. Karlson, Susanne Churchill, Isaac Kohane, Robert M. Plenge