Irritable Bowel Syndrome (IBS) is a functional gut disorder that affects up to 15% of people in the West. Sufferers typically experience abdominal pain or discomfort that is associated with either diarrhoea or constipation, or an alternating combination of both.
The precise cause of IBS is poorly understood and current treatment is focussed on managing the physiological symptoms, with patients typically prescribed antidiarrhoeal medication, laxatives or antacids.
However, at least as far back as 1980 IBS has been consistently associated with a range of psychological dimensions. IBS sufferers are much more likely, for example, to have experienced childhood adversity than non-sufferers, and the onset of symptoms often closely follows an intensely stressful life event.
In around 80% of cases IBS is co-morbid with anxiety, depression and somatisation (the phenomenon in which psychological distress is expressed in physical symptoms), and the greater the degree of psychological distress the more severe the IBS symptoms.
Though this association is well-established only in recent years have we really begun to understand the potential mechanisms underlying this relationship, and the explosion of research in to the gut-brain axis has provided us with a clearer understanding of how psychological or emotional pain might translate in to physical discomfort.
The current hypothesis is that persistent distress (e.g. an unhappy marriage) or chronic stress (such as unrelenting work demands) activates the immune system; the body perceives the stress as an environmental threat and prepares to fight it. This chronic immune activation affects the gut both directly – through communication via the vagus nerve – and indirectly, through inflammatory signalling molecules called cytokines. This immune activation can also disturb the composition and function of the gut microbiome, which may then contribute to further physical symptoms.
The irony, then, is that the typical pharmaological treatments may further disturb gut microbiome function. In addition, in an attempt to relieve their symptoms, sufferers may self-diagnose a food allergy or intolerance and eliminate nutrients from their diet that may exacerbate these imbalances.
However a recently published psychological intervention offers new relief to IBS sufferers and strengthens the case for psychological therapies to form a key feature of IBS treatment.
Researchers led by Elyse Thakur at the Department of Psychology, Wayne State University in Detroit conducted a randomised controlled trial on a specialised form of talking therapy, Emotional Awareness and Expression Training (EAET), aimed at helping IBS patients to better recognise and express their emotions.
The research team compared the treatment to either relaxation training – which has been previously shown to be a helpful treatment – or to a control group of patients on waiting list for intervention. Both the EAET and relaxation groups received three 50-minute training sessions delivered over three consecutive weeks i.e. one session a week. They were assessed two weeks after the end of the last session, and again 10 weeks after that.
Participants in the EAET and relaxation groups received a similar explanation about the link between stress and IBS but the EAET group were provided with specific skills to improve emotional expression such as thinking of someone they have a difficult relationship with and being encouraged to describe those feelings out loud as if the person were present. They were later encouraged to express their emotions directly to that person. In comparison, the relaxation group were coached in muscle relaxation, deep breathing and mindfulness meditation.
At the end of the 10-week follow-up period 63% of the people in the EAET group reported significant improvements in their IBS symptoms while people in the relaxation and waiting list groups did not report any significant change in the severity of their IBS.
What is striking about this result is that the intervention was very brief, less than three hours in total, and the participants had been ill for many years. This could mean, in practical terms, that provision of this kind of treatment might be highly cost-effective.
This was a small study with a short follow-up period, but it builds on the body of research linking psychological stress (chronic stress, unresolved trauma, emotional suppression) with the physical symptoms of IBS.
We know, and have long-known, that IBS is a stress-sensitive disorder, with symptom flare ups often triggered by stressful events, and psychological treatments have demonstrated efficacy in relieving symptom severity and improving quality of life to people living with IBS.
Perhaps it is time to move towards an integrated model of treatment that includes psychological and dietary intervention and, more broadly, it is well time that psychological dimensions were taken more seriously in the wide range of functional disorders and their treatment.
Thakur, E. R, Holmes, H. J, Lockhart, N. A., Carty, J. N., Ziadni, M. S., Doherty, H. K., Lackner, J. M., Schubiner, H. & Lumley M. A. (2017). Emotional awareness and expression training improves irritable bowel syndrome: A randomized controlled trial. Neurogastroenterology, Epub ahead of print. doi: 10.1111/nmo.13143