Mind-Body Therapy for Irritable Bowel Syndrome
By Bridget S. Bongaard MD, FACP, and Melissa Ritchie, BSN. Dr. Bongaard is Director of the NorthEast Internal & Integrative Medicine Program, CMC-NorthEast Medical Center in Concord, NC, and Ms. Ritchie is a holistic nurse at the CMC-NorthEast Medical Center; they report no financial relationship tied to this field of study.
Irritable Bowel Syndrome (IBS) is a chronic gastrointestinal (GI) illness that is defined by symptoms of bloating, lower abdominal pain, and abnormal defecation patterns after evaluation excludes colitis or structural abnormalities as the cause. The patient may present with diarrhea, constipation, or an alternating variety of the two types. IBS, however, is not considered just a disorder of motility, but now has been found to be a "dysregulation of central nervous system-enteric function,"1 better described as the gut-brain axis. It is the most prevalent chronic GI disorder seen in primary care or in gastroenterology, and can also be costly in terms of work days lost for frequent doctor visits, extensive workups, and or hospitalizations. This disorder has been ranked as the second most common cause of illness-related work absenteeism aside from the common cold.2
The symptoms of IBS seem to be an integrated response to a variety of biological and psychosocial factors. Extrinsic (vision, smell) or intrinsic (emotion, thought) sources of information have, by nature of their neural connections from higher centers, the capability to affect GI sensation, motility, and secretion,1 while pain, created by the IBS symptoms, reciprocally affects central pain perception, altering mood and behavior. Dysfunction in this feedback loop of the gut-brain axis may also unfortunately create maladaptive behavior when it comes to eating and defecation, which then amplifies the impact of IBS on a person's quality of life.
Doctors should be able to make a positive diagnosis of IBS based on a patient's history alone, and if necessary, confirmed by diagnostic tests. However, IBS tends to be a diagnosis of exclusion, and frequently a pure physiologic cause cannot be identified. When some patients receive this information, there can be a negative perception, or personal sense of devaluation generated, as if what they are feeling is "all in their head," or purely psychologically based. This unfortunately creates more anxiety and stress for the patient, which then can increase the symptom complex. Health care providers should include in their discussions with patients education on the interaction of biological and psychological factors that could contribute to the diagnosis of IBS. This opens the door to exploration into the psychological dimension without making the patient feel like their symptoms are purely psychosomatic and therefore inconsequential.
Medical management options for patients with IBS are often unsatisfactory for patients, as the range of treatment is limited in scope and efficacy. Pharmacological agents such as antispasmodics, 5-hydroxytryptamine antagonists, antidiarrheals, and laxatives are routinely utilized with varying degrees of success. Other therapies commonly offered include: changes in diet, fiber supplements, and identifying food intolerances. The failure rate of these treatments is high, leading to the conclusion that IBS has a strong psychological component,3 yet there has not been a specific unique psychological mechanism identified.
Role of Stress in IBS
The role of stress in the pathophysiology of IBS is thought to be due to generally altered stress reactivity. Patients with IBS are more apt to be hypersensitive to pain, and to have depression, anxiety, and somatization. Those with chronic psychological stress associated with increased abdominal symptoms, health care-seeking behavior, and surgeries, often have an associated history of trauma and sexual abuse.4 GI-specific anxiety, for example, fear of IBS pain precipitating a hypervigilance of GI symptoms, outweighs general anxiety and neurosis as a predictor for severity of symptoms as well.5 Completing a thorough psychological history therefore is important to uncover these potential treatment land mines as the role of stress in the pathophysiology of IBS, though appreciated, is presently under-evaluated.
Psychological management of IBS could include the use of antidepressants, tricyclic antidepressants, and selective serotonin reuptake inhibitors. The beneficial effects of these agents are independent of mood or anticholinergic effects and are thought to influence psychological pathways leading to reduced somatization and a reduced tendency to regard gut sensations as indicating illness.3 The anticholinergic side effects of the tricyclic antidepressants do confer some additional benefit in IBS patients that have pain and diarrhea, but not those with constipation; selective serotonin reuptake inhibitors are more beneficial in IBS patients that have pain with constipation and bloating.
Cognitive behavior therapy (CBT) shows patients how events, thoughts, emotions, actions, and physiological responses are intertwined. CBT is a short-term strategy oriented to change behavior, which in turn allows the development of new strategies and coping skills rather than the development of insight for its own sake.
Of particular importance are interpretations of internal sensations and external events. Thought patterns are related to underlying assumptions that a person has about themselves and the world. The results of several randomized controlled trials support the use of CBT to treat both individuals as well as groups.3 It is recommended for patients who have a history of sexual abuse, or those who are considerably distressed by their symptoms, yet open to psychological treatment; however, it is not as helpful in women with high anxiety who have IBS symptoms on a daily basis. CBT is as effective as antidepressant treatment, and while its benefits last longer, the combination of the two produces the best response.3
More than 2,000 years ago, Hippocrates recognized the moral and spiritual aspects of healing. He is quoted as saying, "It is more important to know what sort of person has a disease than to know what sort of disease a person has." He also believed that treatment could only occur if consideration is given to attitude, environmental influences, and natural remedies. While the recognition of mind-body techniques predates modern biomedicine, only recently has it been receiving increased attention as biomedical research identifies the mechanisms by which the mind and body influence each other. Mind-body medicine comprises a wide range of practices and modalities designed to enhance the mind's capacity to positively affect health.
In a 1994 national survey on the use of mind-body therapies, Wolsko and associates concluded that almost one in five American adults reported using one or more mind-body therapies in the past year as well as some other form of complementary and alternative medicine.6 Seven percent used meditation; 4.8% used imagery; 3.7% used yoga; 1.4% used hypnosis; 1.4% used stress management; 1.0% used relaxation techniques; and 1.0% used biofeedback. For digestive disorders alone 12.4% used mind-body therapy; and of those, 39.5% found the therapies to be very helpful for their condition. While these therapies are inexpensive self-care-based modalities and hold appeal as cost-effective or cost-saving alternatives, there needs to be supervision by a physician to be sure that they are at least equally as effective as medication, or other standard treatment options.
Hypnosis involves the use of an intentional creation of a daydreaming or trance-type state of consciousness in the patient. This can be achieved by a combination of different methods including deep relaxation, mental imagery, and progressive muscle relaxation; however, there is never any loss of will or consciousness. This trance state serves a as a tool to deliver therapeutic change by opening the door to the mind-body connection. Hypnosis also has been shown to affect smooth muscle reactivity, and is also a valuable aid to relaxation and reducing psychological distress,7 all of which are beneficial to patients with IBS.
When in a hypnotic state it is assumed that a person can better accept and assimilate new concepts and ideas, though the actual mechanism is not clear. According to one theory, there is a subtle shift away from the critical, analytical conscious process involving the left cerebral hemisphere function toward more subconscious, creative, and imaginative processes thought to involve the right hemisphere,7 as well as involvement of the fronto-limbic regions of the brain that control cognitive and attentional processes. This may allow retrieval of unconscious material and insights that pertain to behavior, stress reactions, and the ability to resolve psychological problems.
Hypnosis is believed to relieve smooth muscle reactivity, which can be beneficial in IBS patients. Gupta et al performed a meta-analysis looking at several cohort studies with 20-200 patients that examined the use of hypnosis in IBS patients.8 Approximately 70%-80% of treated patients experienced at least moderate symptomatic relief, and of these, approximately 80% subsequently maintained improvement for up to five years. Identifiable added benefits included reduction of doctors' visits for IBS, and reduced medication needs or frequency of medication use, all of which would result in lower health care costs.
Evidence is accumulating that hypnotherapy can be extremely effective in the majority of patients with IBS. While not a cure, hypnotherapy does put the patient in control, giving them techniques and coping strategies to overcome and relieve their symptoms quickly.
Gut-directed hypnotherapy involves inducing a hypnotic state to create images related to symptom control and normalization of gut function. The technique usually involves 12 weekly sessions beginning with hypnotic induction achieved by progressive relaxation, followed by hypnotic suggestions directed toward improving confidence and general well-being, and then guided imagery to induce control and normalization of gut function and lessening of symptoms.
One such session could focus on imagery such as "seeing one's diarrhea as a fast flowing river that then is imagined to be flowing slowly and smoothly."3 These sessions usually also include the patient placing their hands on their abdomen and inducing a sense of warmth and comfort. The technique is then reinforced or modified as necessary to include other interventions that would help deal with specific issues identified that trigger or exacerbate symptoms.
Mindfulness Meditation/Relaxation Therapy
The relaxation response has deep roots in Eastern philosophy and practices of meditation. For success one must have a quiet environment, comfortable position, passive attitude, and focus on a single thought or meaningful word. During mindfulness meditation instruction, the subject is trained to develop skills that focus on being non-judgmental, and staying in the present moment. For IBS patients, training focuses first on observation of the present symptoms/sensations of IBS, while being non-judgmental to feelings and thoughts that arise.
In a controlled study of IBS patients, Blanchard and Keefer showed that relaxation response meditation was superior to a control intervention with significant improvement in flatulence and belching observed at post-treatment.9 Mindfulness appears to be effective in uncoupling the sensory experience of pain and other somatic symptoms from the affective alarm reaction, thereby reducing the experience of suffering. This also reduces the comorbid anxiety and depression that play a role in exacerbating IBS symptoms, and may enhance the efficacy of CBT in patients with IBS.
Biofeedback relies on the patient's learning to influence bodily functions through special machinery that gives feedback to the patient. It can be used for functional constipation, fecal incontinence, functional anorectal pain, IBS, functional dyspepsia, and aerophagia.10 The benefits of biofeedback can last up to 12 months.
Little research exists on yoga for the treatment of IBS specifically, but considerable evidence supports its place in the treatment of a common comorbidity: anxiety disorders. A study by Gupta et al used interventions including yogic postures, breath work, relaxation technique, meditation, stress management, and nutrition to treat cohorts of patients with different medical problems, including IBS.8 The results indicate that anxiety was significantly reduced with the combined therapies that predominately featured the daily practice of yoga.
In a randomized trial using yoga, Kuttner et al studied 25 adolescents with IBS, and assigned them either to treatment or a wait group.11 The treatment group underwent a one-hour instructional yoga session followed by four weeks of practice guided by a video. The study group as compared to control had lower scores for GI symptoms and pain, functional disability, anxiety, and depression while demonstrating better coping skills. This indicates that yoga can be a useful adjunct in the treatment of IBS.
IBS is a common illness that can be both debilitating to the patient as well as costly in terms of ill health, missed work, and an increased burden on an already strained health care system. It is associated with comorbidities of anxiety, depression, and occasionally neuroticism that complicates the picture and makes treatment more difficult. Simple use of physical treatment with dietary change, fiber addition, and medical regimens of antidepressant medications are not always completely successful, highlighting the need to address the mind-body connection inherent in the illness.
Several mind-body strategies, alone or in combination with standard medical protocols, offer possibilities for a more successful outcome for IBS patients. The use of hypnotherapy, yoga, biofeedback, and mindfulness meditation/relaxation offer adjunctive assistance in conquering this difficult problem, and in some cases yield prolonged improvement not achievable with medication and diet therapy alone. It is imperative, however, that the patient be fully evaluated medically to treat any reversible conditions prior to offering the mind-body strategies.
Depending on the availability of qualified mind-body practitioners in the medical community, referral can be made for any of the aforementioned modalities to achieve relief of IBS symptoms or its intertwining comorbidities of anxiety, stress, or depression. Cognitive behavioral therapy is most useful for those with underlying serious psychological problems such as trauma, abuse, or long-standing chronic anxiety and depression. Hypnotherapy may yield long-lasting results when provided within the context of a series of treatments reinforced by self-hypnosis using autogenic tapes. Yoga, mindfulness meditation, and biofeedback are new applications of traditional modalities that may also offer symptomatic relief. The choice is dependent on patient preference and availability of services to achieve positive outcome in both the physical and psychological function of the patient with IBS.
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