Lifestyle and Behavioral Therapies

Sleep is a key lifestyle factor that can influence IBS symptoms. Research has shown that sleep deprivation is associated with lower pain thresholds, including in patients with IBS. A recent study found that when patients with IBS experienced poor sleep with more frequent nighttime awakenings, they also reported worse IBS symptoms the subsequent day.

Incorporating simple, healthy sleep habits can make a big impact on sleep quality, including:

1. Going to sleep and waking up at approximately the same time every day
2. Ensuring you get enough sleep; most adults need 7-9 hours per day
3. Limiting screen time before bedtime (including phone, computer, or TV)
4. Avoiding large meals, caffeine, and alcohol prior to bedtime
5. Relaxation or meditation in the evening

It's important to acknowledge the bidirectional relationship between sleep and IBS. Poorly controlled IBS symptoms can also contribute to poor sleep. In such cases, a supplement such as melatonin or medication to improve sleep quality may be considered. Some neuromodulator medications (e.g., amitriptyline or nortriptyline), primarily used to treat pain-related symptoms in IBS, have the added benefit of improving sleep. Finally, working with a GI psychologist may be helpful in developing skills to improve sleep.

Brain-gut behavior therapies are behavioral interventions developed to address the brain-gut connection. They have several distinguishing features, including:

• Targeting the drivers of gut-brain dysregulation (in other words, miscommunication between the brain and gut), such as visceral perception, visceral hypervigilance, and GI symptom-specific anxiety.
• Helping patients develop strategies to manage their symptoms better, reduce concerns, worries, and fears related to symptoms, and improve quality of life.
• Being effective at improving IBS symptoms, including abdominal pain, bloating, and bowel changes.
• Differ from traditional psychotherapies in that they are short-term, skills-based, and focus specifically on the brain-gut connection.
• Being durable, meaning they have long-lasting benefits even after treatment is complete.

Brain-gut behavior therapies are provided by psychologists who specialize in gastrointestinal disease (GI Psychologists) and include cognitive behavioral therapy, gut-directed hypnotherapy, and mindfulness-based approaches. Referral to a GI Psychologist is usually part of a larger management strategy, rather than an alternative to medical treatment.

Patients who are good candidates for brain-gut behavioral therapies include those with:

• Symptoms impacted by stress, mood, or emotional factors
• Symptom-related anxiety and/or ineffective coping related to their gastrointestinal symptoms, such as avoidance behaviors
• Moderate-to-severe symptoms that are refractory to medical therapy
• An interest in brain-gut behavior therapies and willingness to engage in developing these skills

CBT is one of the most well-tested brain-gut behavior therapies, with more than 20 randomized controlled trials demonstrating its efficacy. GI-focused CBT prioritizes the relationship between GI symptoms and the thoughts, behaviors, and emotions connected to these physical symptoms. By noticing this relationship, patients can then develop skills to change these thoughts and behaviors and, in doing so, change the way they feel physically and emotionally.

Skills learned in GI-focused CBT include cognitive reframing (changing negative thoughts to be more balanced), developing behaviors to improve coping, and prioritizing relaxation skills to decrease the stress response. Over time, patients who undergo CBT learn skills to help change their responses to both GI symptoms and stress in order to improve their overall experience living with IBS.

Gut-directed hypnotherapy is a deep relaxation technique that takes advantage of a special mental state called trance. When a person is in a state of trance, the mind is very focused and open to suggestion. During hypnosis, the GI psychologist uses relaxation, visual imagery, and suggestions to retune communication between the gut and the brain. Examples of imagery may include a relaxing location that is a metaphor for feeling safe and secure. The suggestions may be that a patient pays less attention to symptoms, has less abdominal pain, and feels confident that they are going to feel better. Hypnosis helps patients change their reactions to GI sensations.

There have been more than a dozen randomized controlled trials showing that the majority of patients with IBS who undergo gut-directed hypnotherapy experience a significant reduction in the intensity and frequency of symptoms. Gut-directed hypnotherapy is a form of medical hypnotherapy and is considered safe and effective.

Mindfulness-based practices are commonly used for patients with IBS, either through a formal Mindfulness-Based Stress Reduction program or through mindfulness exercises integrated into therapy. Mindfulness is a way of paying attention to your thoughts, feelings, body sensations, and surroundings without judging them as "good" or "bad." It originates from Buddhist meditation practices but is now used as a health tool.

The goal of mindfulness is to change the stress response. In patients with IBS, mindfulness can be particularly helpful because it can help patients notice symptoms and negative thoughts without allowing these factors to make them feel worse. Research shows that mindfulness can improve IBS symptoms such as constipation, diarrhea, and bloating; reduce GI symptom-specific anxiety; and decrease visceral hypersensitivity.

If you are interested in exploring brain-gut behavior therapy further, we have included a diaphragmatic breathing tutorial as part of the course. Diaphragmatic breathing is an easy to learn breathing exercise and relaxation technique recommended for patients with IBS. It stimulates the vagus nerve, increasing parasympathetic activity also known as the "rest and digest" system in the body. It is recognized as a treatment for bloating due to abdominophrenic dyssynergia which is common in patients with IBS.

Diaphragmatic breathing is one of the potential therapies you may learn while working with a GI Psychologist.

There are many different ways that patients with IBS can engage in brain-gut behavior therapy, such as seeing a GI psychologist in person or via telehealth, attending group-based therapy, or using online or app-based programs.

Our resources page includes more information about engaging with brain-gut behavior therapies.