The Effects of a Mindfulness Based Intervention on IBD Disability

Crohn's disease (CD), next to ulcerative colitis (UC), is an inflammatory bowel disease (IBD) and causes chronic inflammation of the intestine. Patients suffer from chronic or relapsing symptoms as diarrhea, rectal blood loss, abdominal pain, nausea and weight loss. Next to physical symptoms, a large number of Crohn's disease patients present psychological distress, due to the large impact the disease has on daily life functioning. Depression and anxiety, as well as chronic fatigue are more prevalent in patients with Crohn's disease compared to healthy controls. The disease also significantly affects other biopsychosocial factors, including interpersonal relationships, educational or work-related activities, body image, sleep and sexual functioning. The impact of the disease on these factors translates to the amount of disease related disability Crohn's patients experience during daily life.

With this study, the investigators will evaluate the effects of a mindfulness based psychological intervention on a broad number of disease related disability factors in patients with Crohn's disease. Besides, they would like to measure the effect of the intervention on perceived stress, disease acceptance and perceived control as well as (biomarkers of) disease activity.

In many patients with Crohn's disease, objective markers of inflammation deviate from subjective health outcomes. For instance, patients may report impairing symptoms even in the absence of active disease, often resulting in comorbid psychological distress. Nearly 80% of those with active disease and 50% of those with inactive IBD report substantial fatigue that impairs their health related quality of life (HRQoL). Next to fatigue, other life domains measured by the IBD Disk, a short instrument that can clinically be used as a measure of patient-reported IBD-related disability, are abdominal pain, regulated defecation, interpersonal interactions, education and work, sleep, emotions, body image, sexual functions, and joint pain.

The relation between IBD and stress is bidirectional. Not only are patients with IBD who are experiencing symptoms more likely to have higher levels of perceived stress, but perceived stress also has a strong and consistent association with concurrent and subsequent IBD symptoms. Furthermore, the intervention of choice (mindfulness) was originally developed as a stress reduction method. Depression and anxiety are also more prevalent in the IBD population compared to healthy controls. But not only does the disease influence mental health, mental health will also affect disease activity. A study by Gracie et al. documented a nearly sixfold increase in risk for anxiety symptoms in those with normal anxiety levels but active IBD at baseline. The same study showed a twofold increase in risk of IBD flares, need for steroids and escalation therapy in those with higher anxiety but quiescent IBD activity at baseline. Hence, the investigators chose to also measure depression, anxiety and stress by means of the Depression Anxiety Stress Scale Short Form (DASS21).

Two other important psychological determinants of subjective health are disease acceptance and perceived control over the disease, both integrated in the SHE model. The definition given by Bloem and Stalpers for disease acceptance is "the feeling by the individual that his health condition and the possible constraints on functioning resulting from it, are acceptable and fitting for him as a person" and for perceived control "the belief of the individual that his health condition, in the individual's perception, can be influenced or controlled by himself or by others".

For this study the investigators chose for a mindfulness based intervention. Mindfulness is defined as the ability to notice and observe details about one's present internal and external environment with the goal of non-judgemental and non-elaborative awareness of cognitions, emotions and physical sensations. This allows for reflective (taking time for reflecting) versus reflexive (resulting from behavioral reflexes) reactions to situations or feelings. Mindfulness is achieved through a standard practice, including meditation, body scan practices, yoga and guided focus on different body parts.

Baer et al. proposed five mechanisms by which mindfulness might work to improve symptoms and mood: (1) exposure, by encouraging patients to experience and accept unpleasant sensations without avoidance, (2) cognitive change, by shifting the conceptualization of negative thinking from "reflections of truth" to "just thoughts", (3) self-management, by improving coping skills through enhancing awareness of thoughts, emotions and sensations, (4) relaxation, by indirectly reducing physical tension and autonomic arousal, and (5) acceptance, by promoting non-judgemental awareness of one's own personal experience and reducing maladaptive behaviours aimed at changing the experience.

The goal of the mindfulness intervention will be to teach patients a way of coping with negative emotions without acting on them, letting patients take control of their disease related behaviour and come to better disease acceptance. Where medical treatments fail to take away all disabling symptoms, psychological interventions like mindfulness could offer patients a coping method through which symptoms are experienced as less disabling and patients regain their quality of life. This research may further strengthen the need for a multidisciplinary approach in patients with Crohn's disease.