Functional gastrointestinal disorders (FGIDs), including IBS, are disorders of brain-gut interaction. This means that there is a problem with the way the central nervous system (the brain and spinal cord) and the enteric nervous system (the nervous system of the gut) communicate information back and forth about our digestion, appetite, thoughts, and emotions. The pathway between the brain and the gut is called the brain-gut axis, and it relies on chemical messengers, including serotonin, for communication. Indeed, 95% of your body's serotonin, a neurotransmitter (chemical messenger) which is often known for its impact on mood, sleep, appetite, and sex drive, can be found in your gut! Thus, our emotional state is closely linked to the functioning of our gastrointestinal (GI) tract. In other words, the functioning of our GI tract affects our emotions, and our emotions affect the functioning of our GI tract (Figure 1).
But My Symptoms are Real, Not in My Head!
Individuals with FGIDs are more likely than people without GI disorders to have depression and anxiety, although these can be seen as both risk factors for, and outcomes of, FGIDs. However, even for individuals with FGIDs who do not meet criteria for a psychological disorder, fears and worries that are related directly to their symptoms, known as symptom-specific anxiety, can contribute greatly to the severity of their symptoms. This is where cognitive behavioral therapy (CBT) can be a helpful tool to decrease GI symptoms and improve overall quality of life.
Cognitive Behavioral Therapy (CBT)
CBT is a type of psychotherapy originally developed and used to treat mental health issues, such as depression and anxiety. CBT is grounded in the belief that our thoughts (cognitions), feelings, and behaviors are all related (Figure 2). More specifically, unhelpful thoughts negatively impact how we feel and these negative feelings can impact how we behave. By engaging in unhelpful or maladaptive behaviors, we reinforce our unhelpful thoughts. So, how can CBT address this? By evaluating and modifying our thoughts and behaviors to make them more helpful, we can improve our emotional state. CBT as a treatment tends to be short-term and collaborative. You and your therapist work together to make a game plan to address your symptoms, which typically includes both in-session and at-home practice.
CBT for FGIDs
CBT is not just used to treat depression and anxiety; it has been adapted for use in the treatment of many medical conditions, including FGIDs. Below we'll discuss how CBT may be helpful for managing the symptoms of FGIDs.
Fight or Flight Response
When a person experiences a digestive symptom, it's not uncommon to have negative thoughts about that symptom. Negative emotions (e.g., fear, frustration) put our bodies into a state of autonomic arousal, which is sometimes called the "Fight or Flight Response." Increases in stress hormones, blood pressure, heart rate, and changes in your digestive function are all part of this physiological reaction that occurs in response to perceived danger. Although this response is a crucial evolutionary mechanism meant to keep us safe from threats to our survival, for many people, this reaction can be overused.
The fight or flight response can be triggered even in response to stressful events that are not an actual threat to our physical safety, such as during the nervous anticipation when preparing to give a speech or in response to experiencing discomfort or pain in your abdomen. For individuals who experience chronic stress or uncomfortable physical symptoms, your body may be regularly in a state of autonomic arousal, potentially worsening the physical symptoms you started with.
How Relaxation Training Can Help
The good news is that your body has a physiological response called the parasympathetic nervous system response (sometimes called the "Rest and Digest Response") meant to counter the negative effects of autonomic arousal and help us relax. We can help train our bodies to switch over to this relaxing state by engaging in activities such as diaphragmatic breathing, progressive muscle relaxation, and guided imagery. These techniques, known collectively as relaxation training, are an essential behavioral component of CBT.
Maladaptive Cognitions That Develop with Chronic GI Symptoms
Many people experience chronic pain or GI symptoms for months or even years without adequate relief. Experiencing chronic symptoms, just like other stressors, can impact our cognitions. Over time, those affected may develop maladaptive cognitions related to their symptoms that actually worsen their symptoms. Below are a few examples of common "thinking errors" that individuals with FGIDs engage in related to their symptoms.
Catastrophizing: This is the tendency to believe that something is worse than it is, dwelling on the worst aspects of a situation and believing you are helpless over the situation
Example: "My stomach pain ruins everything!"
Why it's unhelpful: Even if there are elements of truth to a thought, it isn't helpful to focus on the worst aspects of it. In this example, rather than dwelling on how terrible a symptom is, which will increase your negative mood, it may be better to consider how many things you have still been able to do and enjoy, even when you haven't felt your best.
Assuming the Worst: This is the tendency to assume we know the future and that the future is bleak. Sometimes it can be called mind-reading, when we assume we know what others are thinking.
Example: "I passed gas in my exercise class and now everyone thinks I'm gross."
Why it's unhelpful: Assuming the worst in things increases our stress level, which can lead to worsening of GI symptoms, creating a self-fulfilling prophecy. Also, it's usually better not to make assumptions about what other people are thinking. In this example, it may have been obvious to you that you passed gas, but others may not have even noticed! It can also be helpful to ask yourself, "what would I think if a friend passed gas in exercise class?"
Acceptance of Things One Cannot Change
In life we experience all kinds of stressful events, both good and bad. Many stressful events can be seen either as controllable, which we can prepare for before or repair after, or uncontrollable, or largely out of our hands. Similarly, we have two options for how to cope with stressful event. One option is problem-focused/active coping, where we focus our attention on addressing the problem, sometimes through pros and cons lists or action plans. Another option is to use emotion-focused/passive coping, where we divert our attention away from the problem, and toward our own emotional state, which includes activities such as reaching out to friends and family or relaxation strategies (Figure 3).
The term adaptive coping refers to the ability to use the most effective coping strategy based on the particular stressor. Choosing problem-focused/active coping in the face of controllable stressors and emotion-focused/passive coping in the face of uncontrollable stressors is considered the most effective way to approach stressful events. However, engaging in adaptive coping is a skill that some individuals with IBS and other FGIDs have difficulty with. In fact, many with FGIDs are excellent problem-solvers, but may have more difficulty shifting gears when a problem (i.e. GI symptoms) doesn't have an immediate solution. CBT can help those individuals learn to adaptively cope with their symptoms by helping them learn to strike the right balance.
How Do I Know This Works?
Research has shown CBT to be effective in improving bowel symptoms, psychological distress, and quality of life. A recent review and analysis of existing studies (meta-analysis) found that the number needed to treat for CBT in IBS is three, meaning that if three people are treated with CBT, one will clinically improve. This statistic is better than what is seen in several of the most effective FGID medications.
What to Expect
If you're interested in seeing if CBT could be helpful for your GI symptoms, you'll need to schedule an evaluation with a health psychologist, preferably one who has specialized training in working with GI patients. In the evaluation, you'll be asked many questions, including questions about your GI symptoms, your mood, your health behaviors (e.g. diet and sleep), and about stress in your life. Your psychologist will then provide a recommendation about whether CBT, or another behavioral treatment, could be effective for your symptoms, or provide a referral, when necessary. Proper treatment means your therapist will collaborate with your gastroenterologist and sometimes other health professionals who work with you. Your therapist will likely expect you to track your symptoms and discuss their frequency and severity to ensure that your symptoms are decreasing throughout treatment. CBT treatment for FGIDs is typically brief, ranging anywhere from 4–10 sessions.
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Adapted from IFFGD Publication #276: Cognitive Behavioral Therapy for IBS and Other FGIDs by Alyse Bedell, MS, Northwestern University Feinberg School of Medicine, and Laurie Keefer, PhD, Icahn School of Medicine, Mount Sinai, New York, NY.
Last modified on June 11, 2018 at 11:12:23 AM