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.

A survey of gastroenterologists in the United States on the use of central neuromodulators for treating irritable bowel syndrome

“…Enacted or internalised stigma may relate to the perception by provider or patient that the medication is treating a psychiatric problem, particularly when the patient is diagnosed with IBS or other DGBI. 24 For these reasons the terminology has been changing from antidepressants to central neuromodulators. 5 In addition to perceived importance, perceived efficacy was a strong predictor of high-prescribing behaviour.…”

“…Our finding that patients frequently refuse neuromodulator treatment due to potential side effects, lack of understanding of their direct benefits and the associated "psychiatric stigma" suggest that these are important topics to include in IBS education. 24 Patients with IBS often feel inadequately informed about their condition, and therefore, educating patients about IBS, legitimising this disorder, explaining the rationale for neuromodulator use, setting expectations and providing reassurance can increase patients' willingness to accept neuromodulator treatment. 5,14,[33][34][35][36][37] When starting a neuromodulator, it is important to explain to patients that side effects may occur before treatment benefit and usually diminish over time.…”

“…Finally, despite their perceived value (see below), stigma may hinder the prescribing of or adherence to taking central neuromodulators. Enacted or internalised stigma may relate to the perception by provider or patient that the medication is treating a psychiatric problem, particularly when the patient is diagnosed with IBS or other DGBI 24 . For these reasons the terminology has been changing from antidepressants to central neuromodulators 5 .…”

Functional gastrointestinal disorders: History taking skills in practice

“…Some patients may feel misunderstood by health professionals due to perceived or enacted stigma occurring in previous consultations. 9 When presented with functional symptoms in a consultation setting, many clinicians report a negative perception of how the clinical appointment has gone. 2 By recognising and addressing feelings of frustration or uncertainty during consultations, clinicians can avoid enacted stigma towards patients.…”

“…8 Thus, the importance of training to improve physicians' confidence in diagnosing functional gastrointestinal (GI) symptoms and to reduce enacted stigma cannot be overstated. 9 Delaying diagnosis will postpone the initiation of therapy based on the bio-psycho-social model and may lead to over-investigation. 10,11 Early positive identification and diagnosis of FGIDs can improve patients' health and reduce public health costs.…”