Understanding gastrointestinal distress: a framework for clinical practice

Abstract

We describe a framework to help clinicians think about health-related quality of life in their gastrointestinal (GI) patients. We introduce "GI distress" as a clinically relevant concept and explain how it may result from physical symptoms, cognitions, and emotions. The GI distress framework suggests that providers should divide GI physical symptoms into four categories: pain, gas/bloat, altered defecation, and foregut symptoms. We describe how these physical symptoms can be amplified by maladaptive cognitions, including external locus of control, catastrophizing, and anticipation anxiety. We suggest determining the level of embarrassment from GI symptoms and asking about stigmatization. GI patients may also harbor emotional distress from their illness and may exhibit visceral anxiety marked by hypervigilance, fear, and avoidance of GI sensations. Look for signs of devitalization, indicated by inappropriate fatigue. When appropriate, screen for suicidal ideations. Finally, we provide a list of high-yield questions to screen for these maladaptive cognitions and emotions, and explain how the GI distress framework can be used in clinical practice.

Figure 1

Proposed framework of gastrointestinal (GI) distress. GI distress results from the combination of GI physical symptom severity, presence of maladaptive GI cognitions, and resulting GI emotions. Refer to the text for an explanation of each concept depicted in the figure.

Figure 2

GI distress profiles in four hypothetical patients. The GI distress framework suggests that clinicians should evaluate GI symptoms, screen for maladaptive GI cognitions, and evaluate related emotions. The relative influence of these three factors varies from patient to patient. In Patient 1, symptoms are the driving impact on overall distress—not cognitions or emotions. This patient should receive directed therapies for visceral pathology. Patient 2 harbors severe symptoms but also maladaptive cognitions (e.g., “I have no control over my illness”; “there is something seriously wrong with my body”; “I feel stigmatized”). This patient should receive therapies for visceral pathology but should also have his or her cognitions identified and properly addressed. Patient 3 has a high symptom burden, along with high cognitive and emotional distress; treatment may include both medical and psychological therapy. Patient 4 has a relatively low symptom burden but a high cognitive and emotional burden; treatment should address maladaptive cognitions and emotional distress.