Mental Health and the Irritable Bowel Syndrome 

By Wasim Rashid Kakroo

Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. Patient with IBS can present with a wide range of symptoms such as cramping, stomach discomfort, bloating, gas, and diarrhea or constipation, or both. IBS is a long-term ailment that you’ll have to deal with.

What are the symptoms of IBS?

1. Pain and Cramping

The most frequent symptom and a significant component in diagnosis of IBS is abdominal discomfort. Normally, your gut and brain collaborate to control digestion. Hormones, and other signals generated by the beneficial bacteria in your gut interact with your gut nerves to play a role in smooth bowel movements. These cooperative signals get skewed in IBS, resulting in uncoordinated and unpleasant tension in the digestive tract muscles. This discomfort is most commonly felt in the lower abdomen or in the entire abdomen, although it is less common in the upper abdomen alone. Following a bowel movement, pain usually subsides.

2. Diarrhea

One of the three primary forms of IBS is diarrhea-predominant IBS. It affects around one-third of IBS sufferers. In one study of 200 individuals, those with diarrhea-predominant IBS had an average of 12 bowel movements each week, more than twice as often as those without the condition. In IBS, accelerated bowel transit can also cause a sudden, strong desire to go to the washroom. Some patients report that this is a major cause of worry, and that they avoid certain social situations in fear of a sudden onset of diarrhoea.

3. Constipation

IBS can induce both constipation and diarrhoea, which may seem contradictory. The most prevalent kind of IBS is constipation-predominant IBS, which affects approximately half of all IBS sufferers. Stool transit time may be sped up or slowed down due to a disruption in communication between the brain and the intestine. The gut collects more water from faeces as transit time slows, making it more difficult to pass. Having less than three bowel motions each week is considered constipation.

4. Alternating Constipation and Diarrhea

About 20% of IBS patients experience mixed or alternating constipation and diarrhoea. In IBS, diarrhoea and constipation are accompanied by persistent, recurrent abdominal pain. This form of IBS is more severe than the other two, causing more frequent and severe symptoms. The symptoms of mixed IBS also vary more from one person to another. As a result, rather than “one-size-fits-all” advice, this illness necessitates a personalized treatment strategy.

5. Gas and Bloating

In IBS, digestion is disrupted, resulting in increased gas production in the intestines. This might result in bloating, which is unpleasant. Bloating is one of the most common and bothersome symptoms of IBS, according to many people who suffer from it.

6. Food Intolerance

Up to 70% of people with IBS report that certain meals cause their symptoms. Two-thirds of patients with IBS avoid specific foods outright. These people may cut out a variety of items from their diet. It’s unknown why certain foods cause symptoms.

7. Fatigue and Difficulty Sleeping

Fatigue is reported by more than 50% of people with IBS. In one study, 160 individuals with IBS said that they had reduced stamina, which hindered their physical activity at work, in leisure, and in social situations.

IBS is also linked to insomnia, which manifests itself as trouble falling asleep, frequent awakening, and a lack of energy in the morning. In a study of 112 people with IBS, 13% said their sleep was bad.

8. Anxiety and Depression

IBS has also been related to anxiety and depression. It’s unclear if IBS symptoms are a manifestation of mental stress or if the stress of living with IBS makes people more vulnerable to mental health issues.

Anxiety and intestinal IBS symptoms reinforce one other in a vicious cycle, regardless of which occurs first.

In one large study of 94,000 men and women, people with IBS were over 50% more likely to have an anxiety disorder and over 70% more likely to have a mood disorder, such as depression.

How does clinical psychology explain IBS?

The biopsychosocial model, which includes biological, psychological, and (psycho)social variables that can contribute to the development and maintenance of IBS, is the best way to understand its aetiology. According to this model, genetic and environmental variables, as well as unique personality features, might influence the illness. These characteristics can help people create coping mechanisms, which, when they’re no longer effective, can help the disease to develop and progress. Early life experiences, infections, trauma, stress, cultural background, and the degree of support an individual receives are all key psychosocial variables for IBS. Negative life events are thought to be a major risk factor for the onset of IBS. People who have had more (severe or frequent) unpleasant life events have a greater prevalence of IBS and might also have a more severe progression of the illness. A malfunctioning gut-brain axis can result in changes in bowel motility, intestinal immune response, or intestinal permeability, all of which can trigger inflammatory reactions that can lead to visceral hypersensitivity. In addition, the microbiome may play a role in IBS pathogenesis.

How can a clinical psychologist treat IBS?

Psychotherapy is an essential component in the treatment of IBS, in addition to lifestyle modifications, dietary guidance, and medication treatment. Psychotherapy is not required for every patient, but its benefits should be explored early on in patients with limited social support, traumatic events in their past, or dysfunctional relationships. Psychotherapy should also be explored for individuals with psychiatric co-morbidities such as anxiety or depression or those who do not show substantial improvement following treatment with other treatment choices (e.g., medications). According to the National Institute of Health and Care Excellence (NICE) guidelines, patients who do not respond to medicines after 12 months and develop refractory IBS should consider psychotherapy. Psychoeducation, self-help, cognitive behavioral therapy, psychodynamic psychotherapy, hypnotherapy, mindfulness-based therapy, and relaxation therapy are some of the psychotherapy methods that are used by clinical psychologists to treat IBS. Patients who are motivated and open to psychotherapy have a higher chance of success with a psychological intervention. In one study, it was found that psychological treatments reduced symptoms immediately after treatment, and that the reduction remained substantial 1–6 months (short-term) and 6–12 months (long-term) after the treatment began, compared to the group who did not receive psychotherapy.

Now we will discuss each of the psychotherapeutic tools to explain how each of them might help a person with IBS.

1. Psychoeducation:

It is important that the clinical psychologist spends time explaining the medical issue. This includes the disease’s name, development, pathogenesis, prognosis (chances of recovery), and treatment options. This material would be referred to as psychoeducation if it was given according to the bio-psycho-social paradigm. Furthermore, psychoeducation is essential for a trusting psychologist-patient connection, which has a significant influence on the course of the disease and symptom alleviation, respectively. Psychoeducation can also assist in the reduction or avoidance of medical examinations that are unnecessarily repeated (and occasionally intrusive) and/or unsuitable therapeutic approaches, as this could increase the likelihood of an incorrect understanding of the disease which may further harm the patient. A study used psychoeducation about pathophysiology in combination with aspects of cognitive behavioural therapy (CBT) and progressive muscle relaxation for 5 weeks. When compared to the control group, patients in the experimental group reported a substantial reduction in somatic complaints and depressive symptoms, as well as an improvement in quality of life. These effects were found even after three-month of follow-up.

2. Self-Help

A clinical psychologist can also guide a patient towards self-help by comprehensive advice and knowledge on IBS, for which they can provide patients with manuals or guidebooks on IBS. Patients can gain knowledge about their own experiences, coping techniques, and treatment choices. This encourages people to take charge of their own care.

Some of the self-help tips to be considered in the treatment of IBS include:

1. Many people have more bowel movements in the morning than in the evening. Pay attention to your personal biorhythm and attempt to go to the bathroom at the same time every day.
2. Allow your body to empty as much stool as possible, imagining that rectum shape while you assess the movement’s “completeness.”
3. Increase your consumption of soluble fiber-rich foods (not insoluble fibre) over time. Bananas, blueberries, kiwi, oranges, carrots, eggplant, green beans, oats, zucchini, and potatoes with skin are all high in soluble fibre.
4. If you have a persistent need to go to the bathroom, try to delay yourself. Sit quietly near the bathroom and see if you can use breathing relaxation exercises to calm your body until the sensation of urgency fades and you don’t need to use the restroom again. Calming your body will also assist to alleviate any anxiety that is driving your central nervous system to send out more (unnecessary) emptying impulses.

3. Cognitive Behavioral Therapy: 

The majority of psychological treatments for IBS are based on CBT, with the goal of reducing irrational concerns and changing behavioural patterns. While CBT has positive outcomes, it requires a lot of time. As a result, the effectiveness is dependent on the patient’s goal, the professional’s skill, and the resources available. A study found a 50% reduction in gastrointestinal symptoms, anxiety, and depression in the CBT group when compared to baseline symptom ratings.

Another study compared a standardised medical therapy with medications and frequent visits with a gastroenterologist to a combination of progressive muscle relaxation, cognitive behavioural strategies, and problem-solving approaches. After 3 and 6 months, the group receiving extended psychological treatment exhibited a decrease in bowel symptoms as well as an increase in well-being, quality of life, and disease control compared to the control group, whose symptoms remained constant. Thus according to this study, the combination of pharmacological treatment and psychosocial treatments is preferable than medical treatment alone.

4. Psychodynamic Psychotherapy:

Psychodynamic Psychotherapy is a type of psychotherapy that focuses on intra- and interpersonal tensions, as well as how they contribute to the development and maintenance of symptoms. IBS symptoms improve as a result of psychodynamic psychotherapy. Therefore, psychodynamic psychotherapy is also recommended by the world gastroenterology organization for treatment of IBS.

5. Hypnotherapy

Hypnotherapy is a technique for focusing on how you perceive your digestive problems. The therapist attempts to teach the patient bowel control and to modify the patient’s reaction to somatic sensations. Hypnotherapy is recommended by the World Gastroenterology Organization for individuals with IBS who have failed to respond to medication treatment. Hypnotherapy can improve abnormal sensory perception in patients with IBS. Hypnotherapy has also an effect on the processing and perception of visceral stimuli in patients with IBS. However, while it has a higher level of safety and tolerability than medication therapy, it is time-consuming and not always available.

6. Mindfulness-Based Psychotherapy

Mindfulness-based treatment blends stress reduction with aspects of cognitive behavioural therapy. Through this approach, patients have a better understanding of their issues and how to deal with them. In a study that was done to look at the impact of a stress reduction programme on bowel symptoms, quality of life, and gastrointestinal symptom-specific anxiety. It was found that there was an increase in quality of life and a decrease in symptom-specific anxiety after 6 months of therapy. Another study looked at the effects of a stress reduction programme on bowel symptoms, quality of life, and gastrointestinal symptom-specific anxiety in people with IBS. After 6 months of therapy, there was an improvement in quality of life and a decrease in symptom-specific anxiety.

7. Relaxation therapy:

Relaxation treatments such as progressive muscle relaxation and autogenic training attempt to reduce perceived stress since stress can cause physiological arousal, which can lead to an increase in somatic complaints and a disruption in gut-brain connection.

In a more recent study, patients on the waiting list were compared to the benefits of relaxation techniques (progressive muscle relaxation, breathing techniques) and emotional awareness and expression training. Patients first had a low emotional response to stressful situations and interpersonal problems. This might result in avoidance behaviour and a high level of arousal. When compared to the control group, the emotional awareness and expressiveness training reduced the intensity of IBS symptoms after 10 weeks. The emotional training group, as well as the relaxation methods group, saw an increase in their quality of life.

In summary, patients with IBS can benefit significantly through a combination of psychotherapeutic and pharmacotherapeutic interventions and I as a clinical psychologist strongly recommend psychotherapy as an effective mode of treatment for IBS.

• The author is a clinical psychologist and works as a Child and adolescent mental health counselor at IMHANS-K and can be reached at [email protected]

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