When 17th-century French philosopher René Descartes famously remarked “I think, therefore I am”, he invoked an ancient philosophical tradition which proposed that the mind and body - rather than being part of the same system - are actually separate entities.
The unfortunate by-product of this binary mind-body outlook is that those with mental health issues and/or chronic physical conditions have been routinely stigmatised and ostracised.
Prior to the discoveries of modern science and the advances of social tolerance, only physical symptoms could be observed from an objective point of view. Psychological symptoms were therefore seen as defective weaknesses at the core of a person’s being.
Thankfully, times have changed, and society as a whole is taking increasingly sympathetic and holistic stance towards mental illness - especially how it overlaps with physical conditions.
By looking at three different physical illnesses - IBS, Lyme disease, and arthritis - this article examines how acknowledging mind-body connection can revolutionise our ability to diagnose and care for patients who experience both mental and physical symptoms.
- Irritable bowel syndrome (IBS) & anxiety
- Lyme disease & psychiatric problems
- Arthritis & mental health
1) Irritable bowel syndrome (IBS) & anxiety
What is IBS?
“The bowels are at one time constipated, another lax, in the same person. How the disease has two such different symptoms I do not profess to explain…The mental phenomena consequent on it amount, in some cases, to absolute insanity ”
Irritable bowel syndrome (IBS) is a highly prevalent chronic gastrointestinal disorder characterised by changes in bowel habits, abdominal pain and discomfort, fatigue, and bloating. The term “syndrome” refers to groups of symptoms which consistently occur together. These symptoms can change over time unpredictably, flaring up or going into periods of remission where they diminish. That IBS symptoms occur in the absence of any detectable physical or biochemical abnormalities has puzzled doctors for over a century.
IBS affects between 9% and 23% of individuals globally (World Gastroenterology Organization, 2009). It is more frequently experienced by females and during adolescence. The symptoms presented in the syndrome do not perfectly distinguish IBS from other similar gastrointestinal conditions, which means often sufferers have to go through repeated rounds of medical consultations, feeling both dismissed and frustrated before an exclusionary diagnosis is finally given.
IBS is not life-threatening but quality of life is significantly impaired in its sufferers. It also creates an economic burden due to work absences and high GP referral rates. Personal accounts of patients living with IBS are accessible for readers wanting to understand more about the debilitating nature of the symptoms described.
How does it link to mental health?
Although the causes of IBS are largely unknown, studies suggest that psychological factors play a prominent role in both the causation and maintenance of the syndrome. Between 40-100% of IBS patients experience a psychological condition such as depression, generalised anxiety, panic, and phobic disorder.
A significant amount of clinical data attributes the co-morbidity of IBS and psychological disorders to the brain-gut interaction. The often overlooked network of neurons lining the digestive tract is so extensive that it is sometimes referred to as our ‘second brain’. Via neural pathways such as the vagus nerve, our brain is in constant bi-directional communication with our digestive tract. This means that stress, thoughts and emotions can each affect the sensations that we feel in the gut, and vice versa, our gut can send messages back to the brain signalling pain and discomfort or lowering our mood. Scientists have used mouse models to demonstrate how acute and chronic stress alter microbiota in the gut, which can cause anxious and depressive behaviours.
The fact that IBS sufferers are often misunderstood, experience a lack of professional understanding around their condition, and have to deal with recurrent, unpleasant and potentially embarrassing symptoms knowing there is no cure, means they are faced with a vicious cycle of physical symptoms causing them anxiety, and their anxiety worsening their physical symptoms.
How can care be improved for IBS patients?
Currently no known cure exists for IBS, so treatment interventions aim to provide patients with relief from their symptoms and an improvement in their quality of life. The complex nature of IBS means that patients require individualised treatment plans. The following psychological interventions are reported to make living with IBS more manageable:
1) Cognitive Behavioural Therapy (CBT). CBT is a short-term, skills-based therapy approach based on the idea that thoughts affect behaviour, and that by changing our thinking we can change our behaviour. CBT combines psychoeducation, with relaxation strategies, problem-solving skills and exposure techniques. This allows sufferers to identify and challenge the thoughts and behaviours that impact the digestive system and trigger their physical reactions, and how the digestive symptom affects their mood and experience of pain. It also teaches practical coping practices to encourage individuals to face situations they may have previously avoided due to fear of their symptoms.
2) Exercise. Physical exercise such as swimming, walking, running or yoga a daily prescription can help patients control their stress and achieve natural mobility and strength in the gut. If the body is healthy and active, the mind and digestive system will likely be too. Pranayama yoga increases what is known as “sympathetic tone”, which is decreased in ISB-D patients (Taneja et al., 2004) and includes poses such as Pavanamuktasana which specifically aims to massage the intestine and relieve wind.
3) Meditation. Meditation and mindfulness techniques reduce stress, anxiety and depression by inducing physical changes in the body associated with relaxation. Stress reduction and diaphragmatic breathing techniques engage the parasympathetic nervous system, which normalises gut motility and reduces the experience of pain.
2) Lyme disease & psychiatric problems
What is Lyme disease?
Lyme disease is a worldwide infectious disease caused by a specific group of the Borrelia burgdorferi bacteria, which can be transmitted to humans through a bite from an infected deer tick.
Most with the condition will initially develop a circular red skin rash around the area of the tick bite, although not everyone with Lyme disease will develop this symptom. The rash can develop into flu-like symptoms such as muscle aches, headaches, a high temperature, and fatigue.
Lyme disease is hard to treat once it's been diagnosed and becomes even harder the longer the condition goes on. Treatment in the early stages is widely available, including a simple 14 to 21 day course of oral antibiotics to eliminate any trace of infection.
If left untreated, it’s possible for people to experience more severe symptoms such as heart problems, nerve problems, or pain and swelling in joints. In extreme cases, Lyme disease can cause significant neurological damage, and some sufferers can lose the ability to read, write, or even walk.
Currently, there is no consensus among doctors on whether Lyme disease is a chronic condition, meaning that a link between Lyme disease and mental health remains a contentious issue. Public Health England estimates that 3,000 people in the UK have the illness, although Lyme Disease UK argue that this figure is mostly likely an underestimation.
How does it link to mental health?
Lyme disease is one of a group of illnesses known as “great imitators”, because the symptoms can mimic a wide range of medical and neuropsychiatric disorders. According to Lyme Disease Action, more severe cases of the illness can cause a range of psychiatric symptoms, such as memory impairment, panic attacks, dyslexia, seizures, and even psychosis.
As with many chronic conditions (e.g. fibromyalgia, ME/CFS) and autoimmune diseases (e.g. lupus, multiple sclerosis), people with late-stage Lyme disease can often remain undiagnosed because their symptoms are incorrectly attributed to a mental health problem. On the other hand, people who develop Lyme disease may already be suffering from depression or anxiety, which can then be exacerbated by the physical symptoms. All in all, this makes Lyme disease a difficult illness to diagnose.
In a study published in the Journal of Psychiatry, one third of psychiatric patients showed signs of an infection with the Borrelia bacteria. The study also observed a correlation between Lyme disease and sleep disorders, obsessive compulsive disorder (OCD), and ADD/ADHD. Depression was found to be fairly common, ranging from 26% to 66% of Lyme disease patients.
In the same study, 40% of patients with Lyme disease were found to develop neurologic involvement of either the peripheral or central nervous system (CNS), suggesting a possible causation - as well as association - between Lyme disease and psychiatric problems.
How can care be improved for Lyme disease patients?
The lack of consensus on whether Lyme disease can be a chronic condition means that the jury is out on how to treat long-term symptoms.
If a GP thinks their patient has Lyme disease, they’ll prescribe them with a 3-week course of antibiotics. Patients with more severe symptoms will be referred to a hospital specialist for injections of stronger antibiotics. Alternatively, the BMJ recommend two-tier serological testing: the sensitive initial test (ELISA) to then be followed by a specific confirmatory test (immunoblot).
Most people with Lyme disease will recover after antibiotic treatment - even though it can take months. However, as Amy Tan explained in her piece for the New York Times, while antibiotic treatment is effective at alleviating symptoms, it is not necessarily a cure:
“I have my life back but I am not cured. If I go off antibiotics, the symptoms march back. I have permanent bodily damage, including epilepsy, a consequence of 16 lesions in my brain.”
By adopting a holistic approach to Lyme disease and acknowledging that it may be chronic in some cases, doctors can better equip themselves to face this all-encompassing illness on two fronts. Providing antibiotic treatment alone is not always enough, and many patients may need support for persistent psychiatric symptoms. As such, talking therapies may be recommended for people with Lyme disease.
According to the BBC, in the UK there has been a “gradual recognition that a minority of Lyme disease patients do develop long-term symptoms, especially if there has been a delay in treating the infection.” As awareness of the condition increases, more funding can go into the research needed to provide early medical intervention for Lyme disease patients.
If you find a tiny tick attached to your skin or were recently in a lyme-infested area, talk to your GP. Even if you don’t experience any of the symptoms, prevention is preferable to treatment. For more on the illness, visit Lyme Disease UK or the NHS page on Lyme disease.
3) Arthritis & mental health
What is arthritis?
Arthritis affects roughly 10 million adults and children in the UK. There are over 200 types of arthritis and these can affect people in different ways, all over the body.
Rheumatoid arthritis is one of the most common conditions. It’s an autoimmune disease that occurs when the immune system mistakenly attacks the synovium - the cells that line your joints. The resulting build up of cells and fluid creates painful inflammation that permanently stretches the outer layer of the synovium. This causes instability in your joints and means that they often reposition themselves. Other, lesser known symptoms include inflammation of the eyes, lungs and blood vessels, fatigue and flu-like symptoms.
Many people with rheumatoid arthritis experience issues with mobility as a result of foot deformity and pain. The condition can also impact negatively on many different day to day activities, such as driving, sleeping, exercising and completing tasks at work or home. There is currently no cure and early diagnosis is really important to improve treatment outcomes. However, the prognosis of arthritis is much better these days and it’s possible to control the condition with medication. Pharmacological treatment such as painkillers, steroids and disease modifying anti-rheumatic drugs (DMARDs) can help to reduce pain, stiffness and inflammation.
How does it link to mental health?
It’s not hard to imagine that a reduced quality of life, caused by arthritis, could affect your mental health. Aside from the physical impact, patients have reported a negative impact on their confidence, mood and their feelings about their appearance.
A review of 72 research papers reported that diagnoses of depression were much more common in rheumatoid arthritis patients, when compared to the general population. The impact of arthritis can also extend to family members, who may be affected by significant changes in their household responsibilities, social lives and their own mental wellbeing.
Cognitive Behavioural Therapy (CBT) can be useful for reducing depressive symptoms and improving pain management, by identifying and challenging unhelpful attitudes and patterns of behaviour towards the condition. However, the relationship between rheumatoid arthritis and depression is complex and may in fact be bidirectional. This means that whilst rheumatoid arthritis may lead to depression later on, there is evidence to suggest a higher prevalence of the development of rheumatoid arthritis in those who are already depressed.
An emerging theory to explain this is that depression is an inflammatory state, whereby psychological processes interact with the immune system. A recent study of over 10,000 participants, found that levels of C-reactive protein - a measurable marker of inflammation - was higher in participants with depression than those without.
What’s more, anti-inflammatory drugs that are commonly used to treat arthritis may also be effective in reducing depressive symptoms and preliminary evidence suggests that CBT could help to reduce inflammation in rheumatoid arthritis patients.
How can care be improved for arthritis patients?
Living with rheumatoid arthritis can be challenging for a number of reasons and our awareness of this condition in society needs to be improved. Symptoms often go ‘unseen’ which can be isolating and emotionally damaging. Another challenge is that there isn’t a one size fits all treatment, due to the varying severities of the condition, and whilst medications can be beneficial for symptom management, these can lead to unwanted side effects.
It is therefore vital that what is learned through research, is applied in healthcare settings. A mind-body approach towards pain control, including psychological support such as CBT should be taken. Barriers to communication should be removed so that patients feel able to talk about sensitive issues, in order to address them properly. There has been great improvements in online resources, including mindfulness-based pain management and self-help for aspects of daily living such as exercise and diet. However, patients need to be properly signposted to this information in order to benefit from it.
Finally, much more work is needed to understand the ways that rheumatoid arthritis, depression and inflammation are related to each other, as the causal links remain unclear. If you are struggling with arthritis, remember you are not alone and support is available.
As more cases of IBS, Lyme disease and arthritis surface, it becomes evident that these illnesses cannot be separated from the mental health problems that can accompany them.
By studying the link between physical and mental health, we open up new avenues of science and research that can be enormously beneficial to the millions of people around the world who are undiagnosed, misdiagnosed, or live with a chronic health condition that does not yet have a known cure.
Ultimately, the more we approach health from holistic point of view by integrating physical and mental health, the less people get left behind. And with the onset of healthtech and new ways of managing health, new possibilities are opening up for early diagnosis and more effective treatment.
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