Anxiety feels different to different people. Experiences can range from a racing heart to a restless mind, but for many, worry manifests in the gut. At these times, anxiety seems as physical as it is mental. This is due, in part, to the fact that different systems in the body are connected and cannot be completely understood in isolation.1 The brain-gut connection is an example of this as the brain and the gut communicate with one another bi-directionally.2
In 2002, researchers found a strong association of psychiatric disorders (especially major depression, anxiety, and somatoform disorders) in 94% of irritable bowel syndrome (IBS) patients, pointing to the role of psychological factors in the etiology of IBS.3 Other research suggests that stress may contribute to or exacerbate gastrointestinal (GI) conditions such as inflammatory bowel disease and gastroesophageal reflux disease.4 So it might seem logical to deduce that approaches that improve anxiety (like cognitive behavioral therapy, biofeedback, meditation, and yoga) may also improve GI function, at least for those with GI disorders.
Over the past two decades, clinicians within the growing field of psychogastroenterology have been focused on the application of scientifically based psychological principles and techniques to help alleviate digestive symptoms.1 Some research suggests that some mind-body therapies may decrease the body’s stress response by dampening the sympathetic nervous system, enhancing the parasympathetic response, and decreasing inflammation in general.5
A relatively large body of medical literature exists describing the association of psychological factors with functional GI disorders (FGIDs), including increased psychological distress, somatization, stressful life events, history of sexual and physical abuse, and maladaptive coping.6 Integrating psychological therapies as well as treatment modalities such as nutrition, physical therapy, or lifestyle modification may improve patient outcomes.6 These mind-body therapies are defined as “focusing on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health.”7
Cognitive Behavioral Therapy & Biofeedback
Research suggests that psychological interventions like cognitive behavioral therapy (CBT) may be effective for IBS symptoms and FGIDs (IBS, functional constipation, functional dyspepsia, and others like fecal incontinence).6,8-10 The causes of FGIDs are thought to be multifactorial and explained by a biopsychosocial model, which implies complex interactions between the brain, the gut, and the environment.6
Biofeedback has been associated with decreased symptoms in children with functional dyspepsia and in adults with constipation.11,12 As well, two meta-analyses support the efficacy of both biofeedback and CBT for IBS.9,13 Treatment outcomes are often correlated with the number of sessions a patient receives, being less effective with fewer sessions. However, a randomized clinical trial in 2013 found that even a brief, five-week CBT psycho-educational group therapy intervention improved IBS symptoms, and many of the improvements were maintained at a three-month follow up.10 The results from this study were similar to landmark studies published in 2010 on utilizing CBT to improve both IBS symptoms and quality of life.10,14
Yoga & Mindfulness
Yoga is an ancient mind-body therapy that combines physical postures (asanas), breathing techniques (pranayama), and relaxation or meditation in order to balance the mind and body.7 The word yoga, in Sanskrit, is “yuj,” meaning to unite the mind, body, and spirit (kavuri). The relaxing and calming effects of savasana (total relaxation) and pranayama (breath control) have been widely studied and reported.4 Research suggests that yoga practices may reduce the inappropriate activation of the autonomic nervous system; clinical trials on IBS patients have suggested abnormalities in autonomic function and psychological profiles.4
A two-month randomized control study evaluated the effect of mixed surya nadi pranayama yoga postures and select breathing techniques in 21 patients with diarrhea-predominant IBS and found that yoga was at least as effective as loperamide in reducing both anxiety and motility scores in IBS patients.15
Mindfulness-based therapy for IBS patients is based on mindfulness-based stress reduction (MBSR).16 This multi-component approach uses mindfulness skills, such as knowledge over breathing process, conscious eating, and other daily activities, and may lead to reductions in IBS symptoms. “When patients focus on the present moment experience, it is possible to accept pain as a feeling for which they have no definition,” writes Fatemeh Ghandi, in a report on a 2018 randomized clinical trial. “This way, people may understand and experience thoughts and feelings for which they have no definition and, therefore, they can be less controlled by pain, anxiety, and depression.”16
Results from the clinical trial suggest that MBSR improved the quality of life and reduced symptoms in 24 patients with IBS.16 Furthermore, in comparison with emotion regulation treatment, mindfulness group therapy had a greater effect on quality of life, mindfulness components, anxiety, and experimental avoidance, and it reduced irritable bowel syndrome symptoms in the long- and short-run.16
Another interesting study in 2018 involved a group of 55 veterans who reported reductions in trauma-related, irritable bowel, symptom-specific anxiety, and depression symptoms.17 Post-traumatic stress disorder (PTSD) and IBS are comorbid conditions associated with reduced health-related quality of life. Comorbid prevalence is especially high among veterans, ranging from 23% to 51%, but there is limited research on integrative treatments. Fifty-five veterans were involved in this eight-week open trial on the effectiveness of MBSR. Veterans reported reductions in trauma-related, irritable bowel, symptom-specific anxiety, and depression symptoms and greater mindfulness skills immediately post-treatment. At four months post-treatment, 77.5% met PTSD criteria and 40.38% met IBS criteria compared with 100% veteran comorbidity pretreatment.17
Modern science continues to accumulate evidence demonstrating what ancient healing traditions have known for centuries: the GI tract has a central role in chronic, systemic disease. Given the strong mind-body/brain-gut connection, it is clear that when the normal integrity of the GI tract is compromised, distant systemic complaints can result, even in the absence of overt GI symptoms. Integrative approaches may be helpful for reducing symptoms and reestablishing a healthy gut and a healthy mind.
- Keefer L, Palsson OS, Pandolfino JE. Best practice update: incorporating psychogastroenterology into management of digestive disorders. Gastroenterology. 2018;154(5):1249-1257. doi:10.1053/j.gastro.2018.01.045
- Koloski NA, Jones M, Kalantar J, Weltman M, Zaguirre J, Talley NJ. The brain–gut pathway in functional gastrointestinal disorders is bidirectional: a 12-year prospective population-based study. Gut. 2012;61(9):1284-1290. doi:10.1136/gutjnl-2011-300474
- Whitehead WE, Palsson O, Jones KR. Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology. 2002;122(4):1140-1156. doi:10.1053/gast.2002.32392
- Kavuri V, Raghuram N, Malamud A, Selvan SR. Irritable bowel syndrome: yoga as remedial therapy. Evid Based Complement Alternat Med. 2015;2015:398156. doi:10.1155/2015/398156
- Dossett M. Brain-gut connection explains why integrative treatments can help relieve digestive ailments. Harvard Health. Published April 11, 2019. Accessed August 13, 2019. https://www.health.harvard.edu/blog/brain-gut-connection-explains-why-integrative-treatments-can-help-relieve-digestive-ailments-2019041116411
- Reed-Knight B, Claar RL, Schurman JV, van Tilburg MA. Implementing psychological therapies for functional GI disorders in children and adults. Expert Rev Gastroenterol Hepatol. 2016;10(9):981-984. doi:10.1080/17474124.2016.1207524
- Grundmann O, Yoon SL. Mind-body therapies for functional bowel disorders—a review of recent clinical trials. Eur J Integr Med. 2013;5(4):296-307. doi:10.1016/j.eujim.2013.03.007
- Radziwon CD, Lackner JM. Cognitive behavioral therapy for IBS: how useful, how often, and how does it work? Curr Gastroenterol Rep. 2017;19(10):49. doi:10.1007/s11894-017-0590-9
- Ford AC, Quigley EM, Lacy BE, et al. Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: systematic review and meta-analysis. Am J Gastroenterol. 2014;109(9):1350-1365. doi:10.1038/ajg.2014.148
- Labus J, Gupta A, Gill HK, et al. Randomized clinical trial: symptoms of the irritable bowel syndrome are improved by a psycho-education group intervention. Aliment Pharmacol Ther. 2013;37(3):304-315. doi:10.1111/apt.12171
- Schurman JV, Wu YP, Grayson P, Friesen CA. A pilot study to assess the efficacy of biofeedback-assisted relaxation training as an adjunct treatment for pediatric functional dyspepsia associated with duodenal eosinophilia. J Pediatr Psychol. 2010;35(8):837-847. doi:10.1093/jpepsy/jsq010
- Rao SS. Biofeedback therapy for constipation in adults. Best Pract Res Clin Gastroenterol. 2011;25(1):159-166. doi:10.1016/j.bpg.2011.01.004
- Lackner JM, Mesmer C, Morley S, Dowzer C, Hamilton S. Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis. J Consult Clin Psychol. 2004;72(6):1100-1113. doi:10.1037/0022-006X.72.6.1100
- Jarrett ME, Cain KC, Burr RL, Hertig VL, Rosen SN, Heitkemper MM. Comprehensive self-management for irritable bowel syndrome: randomized trial of in-person vs. combined in-person and telephone sessions. Am J Gastroenterol. 2009;104(12):3004-3014. doi:10.1038/ajg.2009.479
- Taneja I, Deepak KK, Poojary G, Acharya IN, Pandey RM, Sharma MP. Yogic versus conventional treatment in diarrhea-predominant irritable bowel syndrome: a randomized control study. Appl Psychophysiol Biofeedback. 2004;29(1):19-33.
- Ghandi F, Sadeghi A, Bakhtyari M, Imani S, Abdi S, Banihashem SS. Comparing the efficacy of mindfulness-based stress reduction therapy with emotion regulation treatment on quality of life and symptoms of irritable bowel syndrome. Iran J Psychiatry. 2018;13(3):175-183.
- Harding K, Simpson T, Kearney DJ. Reduced symptoms of post-traumatic stress disorder and irritable bowel syndrome following mindfulness-based stress reduction among veterans. J Altern Complement Med. Published online August 30, 2018. doi:10.1089/acm.2018.0135
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