There are numerous connections between the gut and the brain (often called the gut-brain axis or GBA), and psychological treatments have proven helpful in addressing problems with this communication system.
The enteric nervous system (ENS), also referred to as the “second brain”, is made up of hundreds of millions of nerves. Patients with IBS can become hyper-aware of how these nerves are behaving or responding to stimuli in the GI tract, and this may contribute to the discomfort IBS patients experience. This is known as visceral hypersensitivity. Unfortunately, there are no diagnostic tests that provide a concrete diagnosis of visceral hypersensitivity, and it can be frustrating to hear when you are in pain.
An understanding of the relationship between pain and the gut-brain axis explains the role your brain plays in this process. It also supports why behavioral medicine interventions can be beneficial for treating IBS symptoms.
The cause of irritable bowel syndrome (IBS) is not completely understood. For various reasons, the symptoms appear to result from altered patterns of muscle contraction in the gut and increased sensitivity to distension and movement of food, gas, or fecal material through the gastrointestinal tract. Also, the bowel appears to be overly reactive to various triggers such as:
- emotional arousal,
- gastrointestinal infections,
- menstrual period,
- or gaseous distension
All of which can exaggerate or perpetuate the symptoms.
Stress and IBS
Stress can also play a role in this process as the GI tract is more sensitive during periods of stress. Stress is variable and can be triggered by a range of activities. Simple daily activities like going to dinner with friends or to the grocery store can cause stress due to concerns surrounding bathroom access or food choices.
During periods of stress, patients with IBS may experience changes in intestinal motility (how fast or slow the digestive process occurs), and/or increased pain or discomfort. When considering treatment options for IBS, stress management may be recommended.
Behavioral Health Specialist
There is now a large amount of positive research showing that certain types of psychological treatments can have a beneficial impact on IBS, but it still may come as a surprise when a behavioral health specialist is recommended. Consulting with a behavioral health specialist to assist with the management of GI symptoms is very different from services one may receive from anxiety or depression. The development of IBS is complex with biological, psychological, and social factors all playing a role in symptom development. For this reason, it has become common to involve a behavioral health specialist with expertise in gastroenterology to aid in treatment.
Common behavioral therapies include:
- gut-focused cognitive behavioral therapy (GI-CBT)
- gut-directed hypnotherapy (GDH)
- acceptance and commitment therapy (ACT)
- other mindfulness approaches
Cognitive behavioral therapy (CBT) works to modify the way you think, feel, behave and react to minimize or eliminate unhelpful thoughts and behaviors. CBT is also used to develop coping skills and to better understand internal and external factors impacting symptoms.
In gut-focused CBT (GI-CBT) a therapist works specifically with patients to determine how they think and behave in relation to their specific symptoms. It is not uncommon for patients to avoid certain foods or environments they feel can cause or worsen their symptoms. Over time, these natural reactions can lead to isolation, distress, and food restriction. A therapist will work to adjust these reactions and improve your confidence in your ability to manage difficult or uncomfortable situations.
Another important focus of GI-CBT is the impact these factors have on your body and your body’s natural stress response. Relaxation skills are often taught to help you learn to reduce tension and discomfort, which directly targets how your nervous system responds to thoughts, feelings, and behaviors.
GI-CBT is one of the most well studied behavioral approaches for IBS, with more than 40 years of research revealing how effective it is for improving IBS symptoms. Data supports its effectiveness via multiple modes of delivery. Individual and group treatment, as well as teletherapy (over the phone or internet) have all proven beneficial.
Gut-directed hypnotherapy is a form of medical hypnosis that has been well researched in patients with IBS. Over 30 published research studies dating back to the 1980s highlight the benefits of this treatment for the mildest to most severe cases. Up to 80% of IBS patients have a positive response to this treatment which are better than those of traditional medications.
Some patients may have misconceptions about hypnosis. Hypnosis does not make you lose voluntary control or cluck like a chicken when a bell goes off. Those concerned that they are not hypnotizable are often happy to learn that approximately 75% of people are able to be hypnotized “enough” to have a positive response.
The goal of GDH is to help gain better control over symptoms by addressing the communication occurring between the brain and gut. Think about your gut and brain as speakers and amplifiers that are not working properly. Your brain is the amplifier and your gut is the speaker. Hypnosis helps you learn how to relax your body, think differently about the sensations you are experiencing, and better regulate the functioning of your mind and gut. Therefore, hypnosis helps you find the most pleasant volume for your amplifier and speaker.
When engaging in GDH, you will want to work with a licensed mental health or health professional with clinical hypnosis and IBS training.
Acceptance and commitment therapy (ACT) is a mindfulness-based behavioral therapy that aims to help patients better understand how they approach various aspects of life. The use of ACT in patients with IBS is still in its early stages compared to the other treatments we have addressed, though it shows promise. ACT was originally developed to help patients with mental health conditions such as anxiety and depression. More recently, it has been found to be effective for chronic pain and other medical conditions. One of the primary goals of ACT is to help individuals learn flexible and effective ways to live with their IBS symptoms.
There are six principles used in ACT to help a person achieve more psychological flexibility:
- cognitive defusion (not getting caught up in your thoughts),
- being present,
- observing self,
- values clarification
- committed action.
A therapist will work with you to learn how each principle helps guide you toward meeting your goals. This type of therapy has also provided patients with skills to decrease avoidant behaviors and anxiety related to their IBS.
Other mindfulness-based approaches often focus on the impact of stress on IBS and the stress that symptoms and the condition can cause. Mindfulness is the act of observing reactions and symptoms in a non-reactive or non-judgmental way. This, in turn, reduces the distress that symptoms cause as well as the stress experienced in the body. In using a mindfulness-based approach, a therapist works with patients to teach them skills such as non-judgmental observation and curiosity about moment-to-moment experiences. This encourages them to notice their symptoms without trying to avoid or change them, and to develop coping skills such as meditation to reduce tense and tight muscles.
The most widely studied mindfulness approach is Mindfulness Based Stress Reduction (MBSR). This approach was designed to help patients with chronic medical conditions. A goal of MBSR is to help patients cope with the impact of pain and the effects pain and illness have on their daily lives. MBSR is most typically taught over 8-weeks in a group or individual setting. Sessions can last up to 3 hours and generally follow a specific protocol. Studies have shown that MBSR can improve the way patients think about their symptoms, improve quality of life, reduce symptom severity, and decrease visceral hypersensitivity.
Adapted from IFFGD Publication #103 Behavioral Treatments for IBS by Megan Riehl & Sarah Quinton PsyD, Director, Behavioral Medicine for Digestive Health, Co-Director, Interdisciplinary Bowel Dysfunction Clinic, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL; Edited by: Darren Brenner, Associate Professor of Medicine and Surgery, Northwestern University – Feinberg School of Medicine, Chicago, Illinois