Deconstructing stigma as a barrier to treating DGBI: Lessons for clinicians

Abstract

Stigma, defined as social devaluation based on negative stereotypes toward a particular population, is prevalent within health care and is a common phenomenon in disorders of gut-brain interaction (DGBI). Characteristically, DGBI including functional dyspepsia (FD) lack a structural etiology to explain symptoms, have high psychiatric co-morbidity, and respond to neuromodulators traditionally used to treat psychopathology. As a result, these disorders are frequently and wrongly presumed to be psychiatric and carry a great deal of stigma. Stigma has profound adverse consequences for patients, including emotional distress, medication non-adherence, barriers to accessing care, and increased symptoms. The basis for stigma dates back to the 17th Century concept of mind-body dualism. Patients and health care providers need to understand the factors that promote stigma and methods to ameliorate it. In this minireview, we address the data presented in Yan et al.'s (Neurogastroenterol Motil, 2020, e13956). We offer concrete solutions for clinicians to mitigate the impact of stigma to optimize treatment adherence and clinical outcomes for patients with DGBI.

Keywords: antidepressants; disorders of gut-brain interaction; functional dyspepsia; neuromodulators; patient-doctor communication; stigma.

FIGURE 1

Patients with symptoms of DGBI come to their physicians looking for a cure for their distressing physical sensations. Physicians perform a workup that turns out to be negative for organic disease and are subsequently frustrated that they did not find anything (the well-intentioned doctor wants an answer, and research shows that physicians have a difficult time managing uncertainty in clinical practice). Perhaps this physician opts to send their patient to another doctor for another workup or the patient self-selects another clinician. In the meanwhile the patient, who is suffering, may develop illness-related anxiety, become preoccupied with these mysterious symptoms, develop hypervigilance around sensations in the gut, and feel frustrated, invalidated, dissatisfied, and helpless. In fact, as emotional distress increases, pain thresholds decrease. More pain results in more referrals, more tests, surgical exploration, the potential for iatrogenic harm, and high financial, time, and emotional burden for the patient