Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction, which produces symptoms of abdominal pain and change in bowel habits in the absence of organic disease.
What are the Mind-Body Interventions?
The National Centre for Complementary and Integrative Health, USA defines mind-body interventions as those practices that “employ a variety of techniques designed to facilitate the mind’s capacity to affect bodily function and symptoms”.
Mind-body interventions utilize the mind’s capacity to affect the body and its physiological responses. They thereby influence health. The response to stress (the “fight or flight” reaction) may be automatic, but recovery toward relaxed parameters (“the relaxation response”) can be learned through self-regulation and the regular use of mind-body interventions.
Mind-Body Interventions
How Do Mind-Body Interventions Work In IBS?
Visceral hypersensitivity means that you have an increased sensitivity to pain sensations in your organs, chiefly the gut. This hypersensitivity manifests as abdominal pain in people with IBS.
Stress has an important relation to IBS. Though stress does not cause IBS, many of you feel that stress worsens your symptoms.
Mind-body therapies work through targeting
- visceral hypersensitivity
- gastrointestinal motility
- stress response
Though the exact mechanism through which mind-body therapies work in IBS is not definitely known, we have enough data to show that mind-body interventions can help people with IBS.
Which Mind-Body Interventions are beneficial in IBS?
- Cognitive Behavioural Therapy (CBT)
- Gut-Directed Hypnosis
- Relaxation Response /Mindfulness Practice.
- Yoga
Cognitive Behavioural Therapy (CBT)
According to the NHS, UK
CBT is a talking therapy that can help you manage your problems by changing the way you think and behave.
((1))
CBT is based on the concept that negative thoughts trap you in a vicious cycle. Your thoughts, feelings, and actions are inter-related. CBT helps you by breaking down your problem into smaller parts and dealing with them in a more positive way.
What Is Included In A CBT Protocol?
Most CBT protocols consist of education modules, wherein you are taught about
- the gut-brain axis
- how to improve bowel habits
- healthy eating habits
- exercise
- managing stress
Does CBT work?
In a recent paper in the journal The Lancet, Gastroenterology, and Hepatology ((2)), called Assessing Cognitive Behavioural Therapy for IBS (ACTIB), people with difficult to treat IBS were divided into 3 groups as follows:
- One group of people received therapist-delivered telephone CBT
- A second group received web-based CBT with minimal therapist support.
- The third group received treatment as usual.
What did they find?
In this study, people were followed up for two years. At the end of that time, 71% of people in the telephone-CBT group and 63% of the web-CBT group were better, compared to 46% of people in the treatment-as-usual group. This means both the CBT groups did better than the treatment-as-usual group. The paper concluded ” Increasing access to CBT for IBS could achieve long-term patient benefit. “
Self-administered CBT for IBS.
CBT is an effective treatment for IBS, but one of the problems is the availability of trained therapists. Additionally, the cost may be a challenge, particularly if it is not covered by insurance. Most CBT treatment for IBS involves 8-12 sessions. Each session of 1 hour may cost between $150-250. That is approximately $1200 to $3000 for the entire treatment. (These numbers are rough estimates only).
What can you do if you do not have access to trained CBT therapists?
A study reported in the journal Gastroenterology attempted to answer this question. ((3)) They performed a randomized controlled trial to assess clinical responses to home-based CBT compared with clinic-based CBT and patient education. People with IBS were assigned to three separate groups.
- One group received standard-CBT which included 10 weekly, 60-minute sessions.
- A second group received 4 sessions of primarily home-based CBT requiring minimal therapist contact. In this group patients received home-study materials covering the same topics as standard-CBT)
- The third group received 4 sessions of IBS education that provided information about the role of stress, diet, and exercise on IBS.
What did they find?
- The home-based minimal contact version of CBT yielded results comparable to the “gold standard” clinic-based version of CBT in improving symptoms of IBS.
- A longer 10-session, clinic-based version of CBT, which required more clinician time, did not have an advantage over a 4-session, home-based version.
- Patients were more satisfied with CBT versus only education.
Gut-Directed Hypnosis
Hypnotherapy for IBS has been in use for many years. In fact, some of the earliest trials are from the 1980s.((4)). Since 2008 hypnotherapy has been included in the UK guidelines for the treatment of IBS.
However, acceptance of hypnotherapy amongst both doctors and patients has been impeded by common misconceptions about hypnosis being loss of control of one’s behavior and being under the “spell of the hypnotist”. In clinical hypnosis, you do not lose control of yourself.
Studies have shown that hypnotherapy improves symptoms in about 76% of people with IBS and the benefits are long-lasting. ((5))That is a very significant number, considering that many people with IBS (particularly IBS-Constipation) are very dissatisfied with their treatment. ((6))
What is clinical hypnosis?
Clinical hypnosis is a treatment process where a clinician helps a patient enter into a specific psychological state which involves deep relaxation and highly-focused attention. Once in this state of hypnosis, the clinician teaches the patient how to gain control of responses and symptoms that are not usually under conscious control.
What is Gut-Directed Hypnosis?
Gut-directed hypnotherapy addresses the “miscommunication” between the brain and the gut. The technique uses relaxation, suggestion, and imagery to produce a therapeutic effect. The suggestions are directed at calming the digestive system. Hypnosis lays great emphasis on helping you understand that you are in control instead of your gut controlling you.
Protocols for Hypnotherapy.
- Manchester Protocol: This was developed by Dr. Peter Whorwell, MD, PhD, at the University of Manchester ( and hence the name). Hypnotherapy is usually carried out on a one-on-one basis by a trained therapist at weekly intervals, each session lasting 30-60 minutes, for 6‐12 weeks. ((5))
- North Carolina Protocol. Developed by Dr. Olafur S. Palsson, PsyD and his colleagues at the University of North Carolina ((7)), this approach uses a completely scripted treatment course. The sessions are provided for over 3 to 6 months. Response rates range from 54% to 95%.
Group Hypnotherapy Versus Individual Hypnotherapy: Is there a significant difference in outcome?
Similar to CBT, individual hypnotherapy costs more and requires trained hypnotherapists. Therefore, can group hypnotherapy provide almost equal benefits?
A study published in The Lancet, Gastroenterology, and Hepatology ((8)) the IMAGINE trial, tested the hypothesis that group hypnotherapy is as effective as individual hypnotherapy for patients with IBS.
The participants were divided into 3 groups:
- Individual hypnotherapy
- Group hypnotherapy
- Educational supportive therapy
The study authors looked at adequate symptom relief as reported by patients.
They found that 40·8% in the individual hypnotherapy group and 33·2% in the group hypnotherapy group felt better. Only 16·7% in the educational supportive therapy group experienced a positive result.
The authors concluded that group hypnotherapy was not inferior to individual hypnotherapy.
What About “Skype Hypnotherapy”?
A study reported in a hypnosis journal looked at providing hypnotherapy over Skype video calling ((9)). When compared to face-to-face hypnotherapy, Skype therapy was slightly less effective, 76% versus 65%. But the advantages were many. People could access Skype sessions from far and the time commitment required was less. Skype sessions were likely more cost-effective too.
Relaxation Response (RR) / Mindfulness (MBSR)Practice
Relaxation Response (RR): Dr. Herbert Benson, a Harvard cardiologist and founder of the Benson-Henry Institute for Mind-Body Medicine USA, defines Relaxation Response as “a physical state of deep rest that changes the physical and emotional responses to stress… and the opposite of the fight or flight response.” ((10))
What has to happen for an intervention to be called Relaxation Response?
During Relaxation Response there should be a reduction in your
- Pulse Rate
- Breathing Rate
- Blood Pressure
What are the different ways to elicit a Relaxation Response?
- Visualization
- Acupuncture
- Massage
- Meditation
- Tai Chi
- Qigong
- Yoga
Relaxation Response in IBS
In a paper in PLoS One ((11)) researchers studied gene expression levels both before and after a 9-week program in patients with IBS and Inflammatory Bowel Disease (IBD). They found beneficial changes in IBS symptoms and reduced gene expression in more than 100 genes involved in inflammation, cell cycle, and oxidative stress pathways. In simple terms, the program helped.
Yoga
Yoga is a mind-body practice that goes back more than 5000 years. Though yoga had started in India, it has now been popularized all over the world.
In a research paper published in the European Journal of Integrative Medicine, where they used a comprehensive Remedial Yoga Module for 12 weeks. ((12)). (The yoga exercises (asanas) are described in the paper).
Participants were divided into 3 groups. One group used only yoga, another used yoga combined with medication and supplements and the third group did not do yoga exercises but were asked to continue their medications and exercise for 60 minutes 3 times a week.
What did they find?
People who did yoga noticed a significant reduction in IBS symptoms, improved quality of life and less anxiety and depression. Interestingly, the adherence rate for yoga was better than for most physical exercise intervention studies.
Virtual Reality (VR) In IBS?
Wikipedia defines VR as an interactive computer-generated experience taking place within a simulated environment. This immersive environment can be similar to the real world or it can be fantastical.
VR in management of pain
This 2017 paper ((13)), did not look specifically at IBS, but the authors used VR for pain relief in hospitalized patients. They compared two groups of patients, one group received a single 3D VR experience and the control group watched high definition nature videos. Pain relief in the VR group was higher in comparison to the nature video group.
Which Mind-Body Intervention Should You Choose?
- There are no specific guidelines for choosing one mind-body intervention over another. It is best to discuss your options with your healthcare provider.
- Your options will depend on what is easily available and cost-effective for you.
- Most of the studies on mind-body interventions in IBS have been done on people who did not respond to treatment as usual. However, you can use a combination of dietary interventions and supplements along with mind-body interventions, all at the same time.
- Using only Mind-body interventions without dietary modifications will not give you the best results.
- Mind-body interventions may not work for you if you have serious psychiatric issues. The decision is best left to a well-trained practitioner.
- How will you select a qualified professional? This link provides information on selecting hypnotherapists, but it will apply to other professionals as well. Beware of anyone promising guaranteed cure!
(In subsequent posts I will discuss diet and supplements in IBS).
