IF YOU’VE SUFFERED FROM irritable bowel syndrome, or IBS, for long enough, chances are a doctor along the way has commented that there’s nothing physically wrong with you, but rather that your symptoms are “all in your head.”
It’s a comment that my patients with IBS find infuriatingly dismissive. If there’s truly nothing physically wrong, then why are they running to the bathroom after eating most restaurant meals, doubled over in pain for hours after eating a salad or unable to move their bowels for days at a time despite a high-fiber diet?
Communication Between Gut and Brain
And yet, there certainly seems to be a very real connection between our state of mind and the state of our digestive system. Despite the very real, very common set of physical symptoms that the estimated 10% to 15% of Americans with IBS experience, many still acknowledge that their emotions and stress levels can also play a role in how their bowels behave. For example, the fear of being late for the airport or having a diarrhea attack at the theater can provoke a marathon toileting session that becomes a self-fulfilling prophecy.
For people who tend to suffer from constipation, the everyday stresses related to work or school can seemingly shut down the bowels for days at a time. In contrast, things may be smooth sailing while on a relaxing vacation. And for some people with mixed-type IBS (IBS-M), there’s no telling whether a given day will bring urgency or constipation. That uncertainty can manifest in frequent abdominal pain, regardless of what’s happening in the bathroom.
Thus IBS symptoms can be both emotionally and non-emotionally triggered. This duality – as both related to abnormal physical functioning of the GI tract and reactive to psychological triggers – can best be explained by a two-way communication channel between the brain and the gut called the brain-gut axis.
We’ve traditionally thought of our brains as the body’s central computer, sending out signals that control the goings-on throughout our body. But communication between the digestive tract and the brain is direct and travels in both directions. Just as the brain can direct physiological responses in the gut – like motility or pain – so too can the gut send signals about the state of affairs within the intestines – like fullness from a meal, presence of gas or the amount of stool on deck – which in turn influence responses in the brain.
Another common example of a disrupted brain-gut communication is when the brain over-interprets normal gastrointestinal sensations – like the movement of gas, spiciness from food, the presence of stool in the colon – as extremely uncomfortable or even downright painful. This phenomenon is often referred to as “visceral hypersensitivity.” GI disorders are certainly not “all in your head,” but at least some of their pathology can accurately be said to originate in your brain.
Historically, treatments for IBS have been aimed at controlling the symptoms: Anti-spasmodic medications shut down an overactive colon, and laxatives help keep stool moving along in an underactive colon. Fiber supplements can help slow down GI transit time and bulk up chronically loose stools. Low-dose antidepressant medications are sometimes prescribed for their ability to dampen nerve-related pain, which reduces pain associated with visceral hypersensitivity.
But sometimes medical interventions fall short of being able to control symptoms satisfactorily. Other times, the severely restricted diets that some patients need to follow to maintain symptom control pose their own set of quality of life issues. Wouldn’t it be nice if there were some treatments that focused on correcting the faulty brain-gut communication that underlies many of the symptoms associated with FGIDs to begin with?
The Field of Psychogasteroenterology
Enter the growing field of psychogastroenterology, in which trained psychologists and clinical social workers are employing a variety of interventions aimed at improving communications between the gut and brain. This is achieved in various ways:
- Retrain the brain to properly interpret signals from the gut.
- Help people who have long suffered from FGIDs to break some of their learned thought and behavior patterns that can feed the vicious cycle of a dysfunctional brain-gut interaction.
With about 30 years of evidence to support the efficacy of various gut-brain directed therapies, the field is finally gaining recognition as a third pillar for the treatment of FGIDs, along with medicine and diet. GI psychologists are employed in the gastroenterology departments of leading academic hospitals.
Psychogastroenterology interventions will vary by patient, and not all patients are good candidates for all therapies. Core evidence-based therapies include gut-directed hypnotherapy – an established, multi-week protocol designed for people with IBS – that’s been demonstrated in multiple randomized controlled trials to improve chronic abdominal pain in both children and adults, with benefits lasting for up to five years following treatment.
Cognitive behavioral therapy helps longtime sufferers of various GI disorders reframe how they view their symptoms, providing essential coping skills that help improve quality of life and may even break some of the thought patterns that can become self-fulfilling prophecies. One aspect of CBT involves “cognitive restructuring.” Patients document their thoughts when symptoms occur to help draw awareness to patterns of hypervigilence to gut sensations and jumping to the worst possible conclusion about where their symptoms might lead (called “catastrophizing”). They are then tasked with ‘rewriting the script,’ or replacing some of these automatic thought patterns with alternate possible responses that may be more measured, balanced and commensurate with the severity of the actual situation. These new mental scripts are practiced again and again until they become more internalized.
Other available interventions include diaphragmatic breathing – a practice that helps relax the entire digestive tract in a manner that can both alleviate urgency in diarrhea-prone people andpromote a release in constipation-prone people who tend to tense up while attempting to move their bowels.
As Dr. Laurie Keefer, GI health psychologist and director for psychobehavioral research within the division of gastroenterology at Mount Sinai in New York, and her colleagues explain in a 2018 paper published in the journal Gastroenterology, “brain–gut psychotherapies are those that leverage the brain’s ability to bring under voluntary control those symptom processes that seem, initially, to be driven completely by the gut.”
In other words, your functional GI disorder is neither “all in your head,” nor is it simply a matter of a dysfunctional GI tract. Rather, it has much to do with a dysfunctional communication between your brain and your gut.