Psychological Effects of Digestive Diseases on Women

Podcast Transcript

Scott Steele: Butts & Guts, A Cleveland Clinic podcast, exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, a colorectal surgeon and president of Main Campus here at Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm very pleased to have Dr. Daphne Spyropoulos, a gastrointestinal psychologist in the Department of Gastroenterology, Hepatology and Nutrition here at the Cleveland Clinic. Daphne, welcome to Butts & Guts.

Daphne Spyropoulos: Thank you so much. Thank you for having me.

Scott Steele: So for the listeners out there, they know we always start with a little bit about yourself. What's your background? Where'd you train, and how did you come to the point that you're here at the Cleveland Clinic?

Daphne Spyropoulos: Sure. So the first thing I have to say is that I'm born and raised in Greece. I'm Greek American, but my first degree I got there and then my master's I got from a university there. And then I moved to New York and went to school at Fordham University where I got my PhD in psychology. And during that time I did training at Harvard Medical School in Massachusetts General Hospital as well as Yale Neurology. And then I did my internship at a psychiatric hospital in Bradenton in Florida. And last year I was at the University of Miami in Jackson Hospital in Miami, Florida. Because I also hear there's a Miami in Ohio, which I didn't know before. And now I'm here.

Scott Steele: Well, we're super excited to have you here. Fordham I believe has a Packer fan of Vince Lombardi heritage to it back in the day. So super excited about that. But today we're actually going to be talking about the psychological impacts of having GI disorders, particularly those unique to women. So to start Dr. Daphne, you practice GI psychology. So can you talk to me a little bit more about that and explain to our listeners what GI psychology is and why is it such a rare specialty?

Daphne Spyropoulos: Absolutely. I wanted to say in terms of GI psychology, essentially what we do is we study the bidirectional relationship between the brain and the gut. So essentially we all know, even people without GI disorders know, that when we get anxious, we tend to get diarrhea or other GI symptoms. But what is new to the party, as I like to say, is that the condition of our gut, so whether there's inflammation going on because of an infection or because of what we've eaten, and then the composition of our microbiome can also lead to something that we call leaky gut syndrome, which essentially means that toxins that are supposed to live in our GI tracts travel through the bloodstream to the brain. And then we've seen that this may affect emotions, behaviors, and my dissertation was actually on Alzheimer's disease and how it's interconnected with the microbiome.

So there's a lot of growth area in psychology in terms of GI. And I think as you mentioned, that it is an understudied field because, first of all, it's new. It's about a decade years old if I am not mistaken. And then I do think that there is unfortunately a lot of stigma associated with having GI symptoms, with anything that has to do with going to the bathroom, incontinence, accidents, anything related to that. And people are hesitant to talk about it, first of all. And second of all, I think in terms of the training that we get in psychology, we don't really get a lot of medical education unless we really want to. I really, really wanted to study things that had to do with clinical health psychology and gastrointestinal psychology, but it's definitely not a traditional path for a psychologist. So there's not a lot of us out there.

Scott Steele: So what role does psychotherapy play in the long-term management of GI conditions? And probably after that, why is it important for a psychologist to be integrated into the medical care of a GI disorder?

Daphne Spyropoulos: I think psychotherapy can play a crucial role in the outcomes of patients with GI conditions. I specifically work with patients with inflammatory bowel diseases and I sometimes play a role of the middle person between the patients and the medical team. Sometimes patients are not comfortable divulging all their emotional things that they've gone through to their medical doctors, but they're more comfortable sharing them with me. They might share concerns that they have about a follow-up appointment, a colonoscopy, any kind of invasive procedure. I founded a women's health and IBD clinic when I first came here. And part of what I do there is pre-screen patients for sexual trauma where essentially I ask them if there's anything that they want me to know, if there are any concerns that they have about potentially invasive procedures such as getting endoscopies, colonoscopies and things like that.

And in collaboration with Dr. Falloon who founded an ultrasound clinic within DDI, we are offering ultrasounds as an alternative to colonoscopies for patients that are good candidates for that in order to make sure that patients that would otherwise decline care would get the care that they deserve instead of dropping out of the system overall, which we see happening.

And also, I do have to say that living with chronic conditions such as inflammatory bowel diseases or motility issues in GI such as irritable bowel syndrome or functional gastrointestinal disorders can have a really big impact on people's quality of life. And we can really help with that. A lot of people have frequent hospitalizations, re-hospitalizations, a lot of surgeries that they have to deal with. A lot of our patients get colostomy bags and they deal with body image issues after that. Their sexual lives are affected and we help patients cope and navigate life with all of this. So I think that psychotherapy definitely plays a big role in helping those patients.

Scott Steele: Yeah. You mentioned this just a little bit, and especially as a colorectal surgeon, I truly appreciate how life-changing something with a colostomy can be. So can you talk a little about maybe some other specific GI disorders that might have a psychological impact on patients?

Daphne Spyropoulos: Of course, of course. So I was thinking about Crohn's and ulcerative colitis in particular because these are the ones that I mostly work with. Not having a sense of control over what's going to happen in terms of the effectiveness of medication, a lot of patients with Crohn's for example, know that the medication that they're on might be effective for a certain amount of time. And just when they feel like they're in control of their lives, they know what to expect from the medication, they don't have to worry as much about incontinence accidents as we call them, or having to find a bathroom everywhere they go. As soon as that happens, sometimes the medication stops working because they build up a tolerance to it and then they have to adjust to life while being in limbo without knowing exactly which medication they need to be on next.

I know that our patients here at the Cleveland Clinic have great access to all the GI providers that are there to help and offer solutions very promptly. But I do know that for people overall, it takes time to get in with a GI provider. And it also takes time for medication to be approved by insurance, which is of course really expensive. So taking that into consideration, a person can really feel like they're lacking a sense of control over their disease and their lives because a lot of people with Crohn's have issues holding down a job and partaking in social activities. Sometimes people tell me, my kid is graduating or getting married, and I don't know if I'll be able to make it because I'm concerned about what if an accident happens, what if I can't get off the bathroom?

And these are really crucial aspects of people's lives and they're things to look forward to usually. And when someone has to deal with chronic health issues such as Crohn's and ulcerative colitis that are also not talked about enough and are associated with symptoms that are stigmatized, such as having incontinence, that can be really debilitating.

Scott Steele: Yeah, absolutely. So can you talk a little bit about what are some of the reasons these GI disorders may affect a patient's mental health, and can you kind of discuss the prevalence of maybe anxiety depression among GI disorder patients?

Daphne Spyropoulos: Absolutely. So I'll start with the prevalence and then I'll go to the first part of the question. So we know that about of a third of patients with any kind of GI condition has anxiety. And about a fourth of, again, patients with any kind of GI condition, whether it's inflammatory bowel diseases, motility issues, functional GI disorders, has depression. So the reasons are multiplex. There can physiological reasons behind it because as I mentioned earlier, there can be inflammation associated with some of these diseases and GI symptoms that then affect on a physical level what's going on in our bodies and can lead to symptoms such as fatigue, pain and a lot of other symptoms that can really aggravate either pre-existing mental health conditions or trigger symptoms that were not there before that patients have to deal with that can then lead to more depression and anxiety. That's the physical way in which that can happen.

And then if we were to look at the lifestyle changes that are needed and associated with having any of these conditions, then a person is called to essentially cope with their life being flipped over. And it really depends on when the patient first gets diagnosed and their access to care and all of these factors that definitely are challenging to cope with and will make people sometimes sad or anxious about the future. And a lot of people have something that we call medical trauma, which is essentially trauma associated with hospitalization, surgeries, pain associated with surgeries that are what we call adverse lifetime experiences, that then leads to mistrust, mistrust to medical doctors, avoidance of getting medical care, having nightmares, flashbacks about getting medical care, which aggravates their sense of distress at baseline, so when they don't have other things going on.

And one last point that's really important is we tend to forget, I think within the medical system, that patients are full humans that have had mental health history before getting a Crohn's, IBS diagnosis, and they might've had anxiety disorders, depression, trauma, any kind of trauma, emotional, physical, sexual, PTSD, bipolar disorder, schizophrenia. All of these things continue to exist and are aggravated by having a life altering disease such as Crohn's, ulcerative colitis, even IBS. So we need to take that into consideration as well.

Scott Steele: So let's focus now specifically on women. Are women at a higher risk of mental health issues when it comes their GI condition? And if so, why?

Daphne Spyropoulos: Yes, unfortunately, we are at a higher risk of prevalence of mental health conditions, especially when having GI symptoms. And there are a few factors why this is happening. The one has to do with the hormonal changes associated with the different life cycles that we're in. So during our menstrual periods and all that, we have hormonal changes that naturally happen in our bodies and then that may cause inflammation in the body, then association with the inflammation caused by GI symptoms that can be even worse. There's a lot of research out there that says that negative affectivity, so essentially women's predisposition towards having negative emotions such as depression, anxiety is higher than men. Now having said that, to be fair, there is a bias in research that's out there or has been, and now we're trying to eliminate that in terms of over-diagnosing women with mental health conditions and misdiagnosing physical health things that might be going on. So this is an entire conversation which actually adds more distress to women.

And then the other thing that I wanted to say is we need to take into consideration all the biopsychosocial factors that affect our lives. So women's roles are changing in society in this historical moment, and they have been for years. We're called to take on a lot of different roles. We're called to be professionals, be moms, wives, partners, do all these things that definitely lead to more stress. And we don't necessarily have a great blueprint as to how to do that, how to be successful at work and successful moms and successful in every other area of life. So that can definitely add to the distress that we have to deal with. And then to add to that, because again, I work with patients with inflammatory bowel diseases, there is a very challenging time in patients' lives when they are going through fertility treatments or when they're trying to get pregnant. It's sometimes harder to get pregnant with inflammatory bowel diseases and patients need to be in remission.

A lot of women internalize guilt for not being able to get in remission, and they think it's their fault, which is something that we see often, unfortunately, across all patients with inflammatory bowel diseases. And then when being pregnant, there are miscarriages and there are high-risk pregnancies as well.

And then the biggest aspect that is not really talked about in research at all, but we need to start talking about it, is perimenopause and menopause that hasn't been studied for years. That definitely also affects women's psychology and our bodies, and it's something that we're all going to have to deal with at some point, but we don't tend to think about it until it's time to deal with it. So all of these factors play a role.

Scott Steele: Yeah, there's no question that it is multifactorial and everything from societal and cultural expectations and even hormonal fluctuations during the menstrual cycle, as you talked about, not only in menopause, but month to month has been shown in the past. So let's kind of switch that around a little bit. So can anxiety and depression actually make the GI condition worse?

Daphne Spyropoulos: Absolutely. I'm glad you asked. So if we were to take the example of somebody who has depression, the symptoms that we see is sadness, anhedonia, a lack of motivation to get out of bed, lack of interest in things that used to give them pleasure before, a lot of fatigue, maybe sleeping too much or not sleeping that much, changes in eating behaviors. I think anyone can relate to this. So when we are feeling down, we don't feel like want to be soldiers in the way that we take care of ourselves and in the way that we eat or we don't always feel like showing up for our medical appointments. And I think truly this happens to everyone. When someone has what we call clinical depression, what that means is that they're having extra challenges in navigating this complex system. I know that in order to schedule an appointment with me, for example, patients have to call different numbers and then respond to MyChart messages, do the pre-check-in and all of that.

When someone's feeling depressed, they're not really feeling up to doing any of that. And then I know that patients with GI conditions have to do this multiple times a week for the most part. And then sometimes what I hear from my patients is I don't necessarily have something to look forward to because I know that at some point my doctor said I need to get a colostomy bag, and then we don't know if that's going to last or if other measures are going to need to be taken. Will I always live with this? Is it going to be reversible? And there are a lot of things that can be really overwhelming for any human, to be fair. So let's not pathologize people. I mean, it's really hard for anyone to deal with any of these issues.

And then with anxiety as well, sometimes there's fear about health appointments, the fear of what if my doctor tells me I have cancer? What if my doctor tells me I need another surgery? What if I have a bowel obstruction? So sometimes anxiety leads to avoidance of medical care, which then aggravates GI symptoms because they're not being treated appropriately. It also leads to unnecessary sometimes ER visits, a lot of extra costs associated with that for the patient, a lot of distress associated with, do I know I'm safe essentially, or do I need to go live at the hospital? That definitely compromises patient's quality of life as well because they can't partake in their social lives or family lives or work lives the way that they would had they not have to deal with all of this.

Scott Steele: So can you talk a little bit about the role of family and friends and basically the supporting structure around someone who has a GI disease?

Daphne Spyropoulos: Of course. Absolutely. I think it's crucial, and unfortunately not everybody has that. And I do have to say, having worked in multiple hospitals in the past, we do see that we all want to feel like we belong and we all want to feel. And in the absence of belonging, there's always suffering. So I've worked with patients before during holidays that actually prefer to be in the hospital than go home alone, even if they don't need to be there. So we all want to feel connected in one way or another. I think family and friends can play a really important role in helping people remember that they're a part of the human species, which essentially means normalizing conversations about incontinence, wearing diapers, having a stoma, having to go to the hospital a lot of times. It's really easy for all of us, I think, and especially for patients with GI conditions, to feel like they're alien to the human species, as I mentioned earlier, and to feel like they're never going to be able to partake in whatever it is that we all think of as normal.

I don't think that there's necessarily a consensus, but sometimes people think that there is a consensus of that. And I do think that family and friends can play a great role in normalizing everything that's going on for people. Also letting them know that they're loved, that there's nothing wrong with them having to have a stoma, for example. I've heard the phrase, which is really devastating from patients, when they say that I think it's disgusting when I have an incontinence accident, or I feel it's disgusting that I have a stoma where you can see essentially what's coming out of my body right there and all of that.

And I truly think, and I see this with my patients, that when they have a support system that normalizes that for them, they have much better outcomes, higher self-esteem, and they don't let that define them and their entire lives. So going back to the we're full humans, I also like to remind that to my patients when they feel like they're just someone who's been inflicted by a disease, I remind them that they're a full person with their own personality, with their own quirks and hobbies and everything that makes them a full human and not just a label or someone carrying a GI condition.

Scott Steele: Truth or myth? Truth or myth? The psychological impact of having a GI disorder diminishes over time.

Daphne Spyropoulos: It really depends. I would like to plead the fifth on this question, but I will say that it really depends on whether patients get care. So some patients don't get psychological care for their ailments and both physical and emotional, so they tend to get worse or stay where they were at before. But for patients that do get care and are a part of an integrative care team that includes psychological support, medical support, they do tend to do a lot better and have their symptoms be treated. And we have seen great results with that. And I do tell people that depression and anxiety are treatable and there are things that people can do, even if sometimes people feel mired in them. There are definitely things that we can do to alleviate at least some of that burden for people.

Scott Steele: And then how can patients maintain a positive outlook and quality of life over time?

Daphne Spyropoulos: That's a really personalized question. I guess it really depends on what people like to do. So in terms of maintaining a quality of life, what I ask them is, what are things that you used to enjoy before getting this diagnosis? Or what would you do if this was a good day? If you were to wake up and you didn't have any incontinence accidents, what would you do? Would you go out on a walk? Would you walk your dog? Would you watch TV? Would you sign up for a hobby or anything like that? So little things like that that we think are insignificant actually play a huge role in mental health.

And something that I tell people, and I'll give this quick example that might help anyone listening with GI issues or depression or anxiety, is something that I call the jar exercise. So what I tell them to do is get a mason jar that's empty and set a goal of I want to leave my house and sit outside in the sun. In Ohio, we do have some sun now. I know we didn't for a while, but sit outside for five minutes or 20 minutes, whatever it is. And every time you go and do that, whether it's a walk or partaking in any other pleasurable activity, you need to collect a little token from the activity. So if it's going outside, you can collect a pebble or a leaf or something like that and then add it to your mason jar. And then your ability to essentially look at the mason jar and look at it fill up is something that we call positive reinforcement in psychology that reinforces behaviors like that.

And there's no magical prescription for feeling better. I mean, medication definitely can help, but in terms of behavioral health and what we can do, it's all the boring stuff that people talk about. So going outside, calling a friend, taking a shower when you don't feel like taking a shower, saying nice things to yourself. It's everything that seems really mainstream and everybody talks about it. Everybody talks about it, but not everybody does it. That's why we keep repeating them. It's not a woo-woo prescription or a Mary Poppins-like thing. It's not going to happen one day. And you don't have to feel like doing something in order to do something. You don't need the motivation to do it. You just need to make yourself do it sometimes. And then you build the momentum that can keep you going.

Scott Steele: So now it's time for our quick cutters, a chance to get to know you a little bit better. So first of all, what was your first car?

Daphne Spyropoulos: My first car was a Jeep Liberty. An '08 Jeep Liberty. Broke down all the time, loved it. He had a name. His name was Takis. Loved it.

Scott Steele: Fantastic. What was the favorite trip that you've been on?

Daphne Spyropoulos: Cambodia.

Scott Steele: Absolutely. And my wife just got back from there. And what is your favorite food?

Daphne Spyropoulos: My favorite, Greek yogurt. Greek yogurt. That's it. I know it's not a good answer, but I love it.

Scott Steele: That's a great answer. I have it in most mornings. And then finally, give us a hidden talent or maybe a talent that not everybody knows you may have.

Daphne Spyropoulos:

Okay. So I am an author technically in Greece, which is great for my career here because nobody here can read what I've written in Greek. But yes, I'm a published author there. So writing is a hidden talent that I have in Greek, not in English.

Scott Steele: I love it. So give us a final take-home message for our listeners with regards to this idea about GI psychology, especially for women's health.

Daphne Spyropoulos: Okay. My tagline that I tell people has to do with incontinence. Can I say the word poop in this podcast or no?

Scott Steele: It's Butts & Guts.

Daphne Spyropoulos: Butts & Guts. That's really fair. So my tagline, and I'll make it a bumper sticker, is it's okay to poop your pants. I say it to patients all the time, I say it to everyone all the time. We need to destigmatize all of it. And it is okay. Hopefully you get help from a gastroenterologist, but it's not a reason to quit living life and give up on being yourself. So it's okay to poop your pants.

Scott Steele: That's fantastic. And so to connect with Doctor Spyropoulos or another clinical health psychologist here at the Cleveland Clinic, please call the Digestive Disease Institute at 216.444.7000. That's 216.444.7000. You can also visit our website at clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. Dr. Daphne, thanks so much for joining us here on Butts & Guts.

Daphne Spyropoulos: Thank you so much for having me.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.