The Gut-Brain Axis
The gut and the brain are in constant communication with each other via the gut-brain axis. This bi-directional relationship is complex and is not completely understood. Do you ever feel nauseous or have abnormal bowel movements before public speaking or a big exam? This is because when you feel stressed or anxious, your body engages the ‘fight or flight’ response. This response diverts energy to the perceived threat, slowing digestion and causing GI symptoms such as constipation/diarrhoea, loss of appetite, bloating and nausea. This ‘fight or flight’ response is orchestrated by your sympathetic nervous system.
You also have a parasympathetic nervous system, which is responsible for regulating our ‘rest and digest’ response. The main component of the parasympathetic nervous system is the vagus nerve, which runs from the brain to the stomach. The vagus nerve acts as a motorway for messages to run from the brain to the gut and vice versa. The GI tract even has its own nervous system called the enteric nervous system, which orchestrates the movement of food through your gastrointestinal tract, regulates gastric acid secretion and blood flow and interacts with the immune cells in the gut. It makes sense why people often call the gut, our second brain.
Is There a Link Between Stress and IBS?
The more we learn about the fascinating relationship between the brain and the gut, the more we discover about the link between psychological factors and IBS symptoms. Living with a functional gut disorder that causes unpredictable and uncomfortable GI symptoms can be very distressing and have a major impact on one’s mental health. This distress subsequently activates our sympathetic nervous system, which sends signals through the vagus nerve to the gut and causes unpleasant GI symptoms. This creates a vicious cycle, whereby the functioning of our GI tract affects our emotions, and our emotions affect the functioning of our GI tract. Indeed, research has shown that individuals with IBS have higher levels of circulating stress hormones, heightened activation of the sympathetic nervous system, visceral hypersensitivity and altered pain perception (1).
Can Behavioural Therapy Help with IBS Symptoms?
There is growing recognition of the impact that physiological factors can have on the management of IBS. Behavioural therapy is now an integral part of the management of IBS and is included in the National Institute for Health and Care Excellence (NICE) guidelines. Behavioural therapy is increasingly becoming a more accessible option for those with IBS. Currently, the most evidence-based behavioural options are gastrointestinal-focused cognitive behavioural therapy and gut-directed hypnotherapy (2).
What is Gastro-intestinal-focused CBT?
CBT is based on the relationship between cognition, feelings and behaviours. GI-CBT is a type of cognitive behavioural therapy that targets the signals going from the brain to the gut. As discussed above, feelings of stress and/or anxiety engage the ‘fight or flight’, causing GI discomfort and exacerbating IBS symptoms. Some individuals with IBS have been reported to have a tendency to catastrophise pain, magnifying the actual or anticipated pain which subsequently impacts their ability to cope with IBS symptoms. CBT focuses on reframing negative thoughts to reduce stress related to IBS, de-catastrophising pain associated with IBS symptoms and helping the individual to understand the impact their emotions have on their GI symptoms (3).
The Irritable Bowel Syndrome Outcome Study (IBSOS) studied 436 participants who received either 4 sessions of home-based CBT, 10 sessions of clinic-based CBT or IBS education sessions. 69% of participants in the two CBT groups showed symptom improvement and this improvement was maintained at 12-month follow-up, suggesting that the benefit of CBT for IBS persists well after treatment completion (4).
Researchers have also investigated the efficacy of virtually-delivered CBT, including telephone and internet-delivered CBT. A large, randomized control trial found that telephone-based and web-based CBT was effective for refractory IBS and treatment response remained at 24 months (5). Virtually based CBT could provide a convenient and cost-effective therapy for individuals with IBS and may become more widespread in the future (6).
What is Gut-Directed Hypnotherapy?
Gut-directed hypnotherapy is a type of clinical hypnosis that aims to recalibrate the communication between the brain and gut, relax the GI muscles and reduce sensory overstimulation. Patients are guided into a state of hypnosis by a qualified therapist, using suggestions, imagery and metaphors that typically focus on the health and function of the GI tract. The idea is that when you are in a state of hypnosis, your brain gets a break from the usual sensory overload and becomes more receptive to new ideas. The treatment typically involves 7-12 sessions over 12-16 weeks (3). Patients are taught and encouraged to practice these hypnotic exercises at home using audio and recordings.
The evidence surrounding gut-directed hypnotherapy is growing (3). An Australian study compared gut-directed hypnotherapy and the low FODMAP diet, both treatments were found to significantly improve IBS symptoms (7). Reduction in pain, bloating, wind and nausea were reported by subjects in the hypnotherapy group for 6 months following the course of hypnotherapy (7). Long-term improvements in IBS symptoms of up to 6 years have also been shown with gut-directed hypnotherapy (8).
Should you use Behavioural Therapies to Manage your IBS?
The use of behavioural therapies in the management of functional disorders of the gut-brain axis is a relatively new field of research, that we are still unraveling. Whilst we have a lot to learn, the results thus far are promising. Behavioural therapy for IBS does not replace diet and/or pharmacological treatment but rather can be used in conjunction with these treatments to allow for a holistic approach to manage IBS symptoms at an individualized level. NICE now recommends that behavioural therapy should be considered for people with IBS who do not respond to pharmacological treatments after 12 months.
It is important to note that what works for one person with IBS may not work for another, and it may take a few trials and errors to identify what is best for you and your gut. We recommend that you speak with your GP about your IBS symptoms.
- Talley NJ. What Causes Functional Gastrointestinal Disorders? A Proposed Disease Model. Vol. 115, American Journal of Gastroenterology. 2020.
- Laird KT, Tanner-Smith EE, Russell AC, Hollon SD, Walker LS. Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis. Vol. 51, Clinical Psychology Review. 2017.
- Chey WD, Keefer L, Whelan K, Gibson PR. Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome. Vol. 160, Gastroenterology. 2021.
- Lackner JM, Jaccard J, Radziwon CD, Firth RS, Gudleski GD, Hamilton F, et al. Durability and Decay of Treatment Benefit of Cognitive Behavioral Therapy for Irritable Bowel Syndrome: 12-Month Follow-Up. Am J Gastroenterol. 2019;114(2).
- Everitt HA, Landau S, O’Reilly G, Sibelli A, Hughes S, Windgassen S, et al. Cognitive behavioural therapy for irritable bowel syndrome: 24-month follow-up of participants in the ACTIB randomised trial. Lancet Gastroenterol Hepatol. 2019;4(11).
- Lalouni M, Ljótsson B, Bonnert M, Ssegonja R, Benninga M, Bjureberg J, et al. Clinical and Cost Effectiveness of Online Cognitive Behavioral Therapy in Children With Functional Abdominal Pain Disorders. Clin Gastroenterol Hepatol. 2019;17(11).
- Peters SL, Yao CK, Philpott H, Yelland GW, Muir JG, Gibson PR. Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2016;44(5).
- Lindfors P, Unge P, Nyhlin H, Ljótsson B, Björnsson ES, Abrahamsson H, et al. Long-term effects of hypnotherapy in patients with refractory irritable bowel syndrome. Scand J Gastroenterol. 2012;47(4).