Melissa Hunt, PhD - University of Pennsylvania Department of Psychology
People with chronic GI disorders fall into two large categories – those with functional disorders like Irritable Bowel Syndrome (IBS) and those with disorders in which tissue pathology and other pathognomic indicators can actually be identified, like the Inflammatory Bowel Diseases including Crohn’s and ulcerative colitis. Surprisingly, both groups can benefit enormously from cognitive-behavioral therapy.
IBS is characterized by recurrent abdominal pain that is relieved by defecation, and is accompanied by abnormalities in the frequency and/or form of bowel movements (i.e. characterized by constipation, diarrhea or an alternating mix of the two.) In practice, individuals with IBS often experience urgency and develop a number of maladaptive coping strategies, most of which are designed to help them avoid visceral sensations and the possibility of needing to get to a bathroom urgently and not making it “in time.” Many people with IBS develop catastrophic cognitions about pain, about the possibility of incontinence and about the potential repercussions, both socially and occupationally, of needing the bathroom both frequently and urgently and not being able to “hold it.” Many people with IBS also develop considerable avoidance behaviors which can meet diagnostic criteria for agoraphobia. Avoidance can include many feared “danger” foods which are believed to “trigger” IBS “attacks” and avoidance of situations in which getting to a bathroom quickly and unobtrusively might be difficult. That includes numerous venues (malls, parks, stadiums, concerts, places of worship) and numerous situations (long drives, trains, planes, work environments that prohibit quick exits such as classrooms, reception, factory work, conference calls, and so on.) In many ways, IBS falls at the intersection of panic disorder with agoraphobia and social anxiety disorder, along with significant health anxiety and catastrophizing about both pain and other visceral sensations.
Fortunately, CBT is very well adapted to tackle both catastrophic cognitions and maladaptive avoidance behavior. Indeed, CBT is the intervention with the most empirical support in the treatment of IBS. With a little knowledge and minor adjustments, most CBT practitioners can probably address the concerns of IBS patients. First, one should always start with a good assessment, including coordination of care with medical providers in order to review the patient’s medical history and the various diagnostic procedures they have undergone. In most cases, the diagnostic tests will all have been negative. If the patient has not been tested for celiac disease (an autoimmune disorder that leads to true gluten intolerance), they should be, as this is an important differential medical diagnosis to rule out. However, extensive, invasive testing, including colonoscopy and endoscopy is not recommended by current medical guidelines , unless the patient has “alarm” symptoms (such as blood in the stool, inflammatory markers in the blood or stool, fever, nutrient deficiencies or unexplained weight loss) that may signal an underlying inflammatory process (Brandt et al., 2009). The next step is psychoeducation about how stress can result in sympathetic nervous system arousal and reduced parasympathetic autonomic activity that directly affect the gut. This is important because it provides the rationale for relaxation training and stress management strategies like cognitive restructuring and CBT more generally. Next comes relaxation training, especially deep diaphragmatic breathing, which has been shown to optimize GI motility, as well as sympathovagal balance and heart rate variability.
Once the patient has a better grasp on the relationship between stress, distress and GI discomfort and is using deep breathing (and/or other strategies including mindfulness, imagery, progressive muscle relaxation and so on) effectively, the therapist can move on to the basic CBT model, introducing the notion that beliefs (not situations) affect our emotions and that beliefs can be right or wrong. This is all standard CBT fare (thought records, benign alternatives, evaluating evidence) but will often have to focus on situations in which the person’s gut is acting up. Behavioral experiments are an important part of this process. For example, send the patient to a movie theater or house of worship, have them sit in the very back, and count how many people actually get up at some point to leave and then come back. They will be surprised by how often this happens and how little most people react.
Finally, in vivo exposure therapy that reduces behavioral avoidance is a crucial part of every successful treatment for IBS. This may need to include food (hint – there are no “danger” foods), food-related situations, abdominal sensations, and any situation the person avoids for fear of not being able to get to a bathroom in time. Using standard in-vivo exposure strategies (e.g. constructing a fear hierarchy and working up it using graded exposure) works quite well. For example, if the person is afraid of long car trips, have them sit in the car in their driveway for 30 minutes. Then progress to driving around the block near their home 20 times. Then drive a mile away and drive back. At home, when they feel the urge to defecate, see if they can delay going to the bathroom for 1 minute. After mastery of 1 minute then try increasing the duration of time (2,3…5 minutes) so the person learns that they can indeed “hold it” without experiencing incontinence. Such exposure can be a huge confidence booster.
Another important area to target is “subtle” avoidance, especially use of a pharmacopeia of medications including anti-diarrheal agents, anti-gas agents and antacids. Patients will often insist that it is perfectly rational and sensible to use these medications, but further probing will often reveal that they are using them in maladaptive ways that perpetuate the cycle of anxious avoidance. For example, if the person knows they have a stressful day coming up at work, they may take one or two Imodium before they even leave the house just in case. Many will recognize such safety behaviors as similar to those seen in people with panic disorder who use benzodiazepines PRN to fend off possible panic attacks. Whether or not the person also meets diagnostic criteria for anxiety disorders, this safety utilization behavior will maintain distress if not targeted in treatment. Moreover, while anti-diarrheal medications are quite safe, they can cause constipation and bloating and thus also perpetuate further avoidance and distress and maintain maladaptive beliefs. For example, people can become convinced that needing to poop is a catastrophe to be avoided at all costs. Turns out that getting people to stop using these medications on a regular basis is an important part of reducing GI specific catastrophic cognitions and visceral sensitivity, and ultimately it actually leads to reductions in abdominal discomfort and urgency.
Many IBS patients can benefit from a self-help book that makes this entire protocol accessible and easy to implement on their own. Reclaim Your Life from IBS: A Scientifically Proven Plan for Relief Without Restrictive Diets (available at Amazon or Barnes and Noble online) was tested in a randomized controlled trial and was shown to be quite effective (Hunt,Ertel, Coello, & Rodriguez, 2014). It can also be used as a treatment manual or guide for interested clinicians.
Unlike IBS, inflammatory bowel diseases lead to actual tissue damage and can have life threatening complications. They are auto-immune disorders that have a genetic basis and are probably related in part to disruptions in both the immune system itself and the microbiome of the gut. They are less prone to stress related exacerbations than IBS (Kovács & Kovács, 2007) but stress is still implicated in symptom exacerbation and relapse (Sajadinejad, Asgari, Molavi, Kalantari, & Adibi, 2002). In addition, CBT for GI disorders can have a very positive effect on health related quality of life, catastrophizing, visceral sensitivity and the secondary depression and anxiety that accompany many chronic and serious health conditions. CBT for IBDs varies somewhat from CBT for IBS, in that people may actually need to get to rest rooms urgently, may struggle with fecal incontinence, and may require significant medical management to target both the underlying inflammatory/auto-immune problems and the symptoms themselves. For individuals with IBDs, it is important to learn to distinguish between abdominal discomfort that can be safely ignored and abdominal pain that signals either a flare or a serious complication like a small bowel obstruction. There is a current trial ongoing at the University of Pennsylvania testing a self-help CBT protocol for IBD patients against an active psychoeducational control. If you know an IBD patient who might benefit from a GI informed approach to CBT, consider encouraging them to enroll in the trial. They can learn more at IBD-Study@psych.upenn.edu.
Brandt, L. J., Chey, W. D., Foxx-Orenstein, A. E., Schiller, L. R., Schoenfeld, P. S., Spiegel, B. M., & ... Quigley, E. M. (2009). An evidence-based position statement on the management of irritable bowel syndrome. The American Journal Of Gastroenterology, 104 Suppl 1S1-S35. doi:10.1038/ajg.2008.122
Hunt, M., Ertel, E., Coello, J., & Rodriguez, L. (2015). Empirical Support for a Self-help Treatment for IBS. Cognitive Therapy & Research, 39(2), 215-227. doi:dx.doi.org/10.1007/s10608-014-9647-3
Kovács, Z., & Kovács, F. (2007). Depressive and anxiety symptoms, dysfunctional attitudes and social aspects in irritable bowel syndrome and inflammatory bowel disease.International Journal Of Psychiatry In Medicine, 37(3), 245-255. doi:10.2190/PM.37.3.a
Sajadinejad, M. S., Asgari, K., Molavi, H., Kalantari, M., & Adibi, P. (2012). Psychological issues in inflammatory bowel disease: an overview. Gastroenterology Research And Practice, 2012106502. doi:10.1155/2012/106502
Published July 28, 2016