Psychological Therapies for Irritable Bowel Syndrome

For the estimated 11.2% of individuals living with irritable bowel syndrome (IBS) worldwide, frequent pain, substantial disability, and reduced quality of life are common challenges. Although a range of pharmacologic treatment options are implemented when lifestyle and dietary changes prove insufficient, many patients do not adequately respond to these medications.¹

A sizable body of research has demonstrated elevated rates of psychiatric comorbidities in IBS, with depression and anxiety disorders affecting up to 70% and 50% of patients, respectively. This association has been attributed to dysregulation of the gut-brain axis, although the exact underlying mechanisms remain unclear.¹

“There is an increased incidence of psychiatric disease antedating the onset of IBS, suggesting that descending neural signals can impact on intestinal neural response,” as explained in a recent interview with Charles N. Bernstein, MD, distinguished professor of medicine, Bingham Chair in Gastroenterology Research, head of gastroenterology, and director of the Inflammatory Bowel Disease Clinical and Research Centre at the University of Manitoba in Winnipeg, Canada. “The psychiatric morbidity that is evident after diagnoses of IBS may be secondary to neural messages from the gut to the brain or simply the stress of chronic physical symptoms on psychiatric health.”

Additionally, childhood trauma and other sources of early life stress have been linked to the development of IBS in adulthood, and psychological stress is a well-established risk factor for the activation and exacerbation of IBS symptoms.²

Given the close relationship between IBS and mental health, the use of psychological modalities represents a growing area of interest in IBS management. According to the National Institute for Health and Care Excellence (NICE) guidelines, psychological therapy should be considered for patients with refractory IBS.¹ Psychoeducation, stress management, and relaxation techniques may provide symptom relief for many patients, and more intensive strategies may be warranted for those with persistent symptoms.

While psychodynamic and mindfulness-based therapies have shown encouraging results for IBS symptom improvement, gut-directed hypnotherapy and cognitive behavioral therapy (CBT) are the psychological approaches with the most supporting evidence for IBS treatment thus far.¹

Hypnotherapy

Numerous studies conducted in this population over the past several decades have noted the effectiveness of gut-directed hypnotherapy, which “combines body relaxation and mental exercises to influence pain sensation in IBS patients.” In this approach, the patient is “placed in a trance-like state of relaxation…. and given suggestions for how best to improve their IBS symptoms.”²

Findings have shown reductions in pain and colonic motility, along with improvements in mood and other extracolonic symptoms, in patients who underwent gut-directed hypnotherapy. These changes persisted for up to 5 years following treatment.²

A course of gut-directed hypnotherapy typically consists of 12 weekly sessions delivered over a 3-month period. However, a randomized trial conducted by Hasan et al demonstrated similar improvements in “IBS symptoms, noncolonic symptoms, anxiety, depression, and quality of life” in patients who completed 6 vs 12 sessions of hypnotherapy. In addition, dropout rates were lower with the 6-session treatment course compared with the 12-session course.³

CBT

CBT aims to modify maladaptive beliefs and behaviors that may influence symptoms in various disorders. As the general gold standard in psychotherapeutic interventions, CBT has repeatedly shown efficacy in a wide array of conditions including depression, anxiety disorders, chronic pain, and insomnia.^2,4

Multiple studies have also found beneficial effects with CBT delivered in a variety of formats to patients with IBS. One approach in which CBT may be tailored to IBS symptoms is by targeting the visceral anxiety that can worsen IBS symptoms. This approach utilizes psychoeducation, self-monitoring, and cognitive restructuring, as well as interoceptive and exposure exercises.⁵

Emerging findings suggest similar or superior efficacy with self-directed and online CBT compared with traditional models.¹ In a 2018 study by Lackner et al, 436 patients with IBS were assigned to receive either standard CBT consisting of 10 weekly sessions, primarily home-based CBT with minimal therapist contact (MC-CBT), or IBS education delivered over 4 sessions.⁶

At a 12-week follow-up assessment, greater improvement in gastrointestinal symptoms was observed in the MC-CBT group (61%) compared with the education group (43.5%). There was no apparent advantage in the standard CBT group compared with the MC-CBT group. Patient satisfaction was significantly higher in both CBT groups compared with the education group (P <.05).⁶

Similarly, in a 3-arm randomized controlled trial conducted by Everitt et al, a total of 558 patients with refractory IBS were assigned to therapist telephone-based CBT (TCBT), web-based CBT (WCBT) with minimal therapist contact, or treatment as usual (TAU). At the 12-month mark, IBS symptom severity scores were 61.6 points lower (95% CI, 89.5-33.8; P <.001) in the TCBT group and 35.2 points lower (95% CI, 57.8-12.6; P =.002) in the WCBT group compared with the TAU group.⁷ Additionally, there were greater 12-month improvements in Subjective Global Assessment scores in the TCBT (84.8%) and WCBT (75.0%) groups compared with TAU (41.7%).⁷

Such results are promising in light of the labor-intensiveness, time commitment, and higher costs associated with therapist-led CBT compared with models that include less therapist involvement.¹ Further investigation is needed to confirm these observations. The potential increased availability of self-guided CBT for patients with IBS could vastly increase treatment access and improve outcomes at a lower cost and inconvenience for patients.

“As mental health can impact on physical health, it is incumbent on physicians to inquire about their patients’ mental health and to provide intervention or referral when mental health comorbidity is identified,” Dr Bernstein advised. Among the remaining research gaps in this area, there are “great needs for clinical trials assessing a variety of interventions and brain mechanisms relevant to IBS,” he concluded.

References

1. Hetterich L, Stengel A. Psychotherapeutic interventions in irritable bowel syndrome. Front Psychiatry. Published online April 30, 2020. doi:10.3389/fpsyt.2020.00286
2. Orock A, Yuan T, Greenwood-Van Meerveld B. Importance of non-pharmacological approaches for treating irritable bowel syndrome: mechanisms and clinical relevance. Front Pain Res. Published online January 21, 2021. doi: 10.3389/fpain.2020.609292
3. Hasan SS, Whorwell PJ, Miller V, Morris J, Vasant DH. Six vs 12 sessions of gut-focused hypnotherapy for irritable bowel syndrome: a randomized trial. Gastroenterol. 2021;160(7):2605-2607.e3. doi:10.1053/j.gastro.2021.02.058
4. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(2):263–298. doi: 10.5664/jcsm.8988
5. Kinsinger SW. Cognitive-behavioral therapy for patients with irritable bowel syndrome: current insights. Psychol Res Behav Manag. 2017;10:231-237. doi:10.2147/PRBM.S120817
6. Lackner JM, Jaccard J, Keefer L, et al. Improvement in gastrointestinal symptoms after cognitive behavior therapy for refractory irritable bowel syndrome. Gastroenterol. 2018;155(1):47-57. doi:10.1053/j.gastro.2018.03.063
7. Everitt H, Landau S, Little P, et al. Therapist telephone-delivered CBT and web-based CBT compared with treatment as usual in refractory irritable bowel syndrome: the ACTIB three-arm RCT. Health Technol Assess. 2019;23(17):1-154. doi:10.3310/hta23170

This article originally appeared on Gastroenterology Advisor