All in my head or all in my gut? An update on irritable bowel syndrome.

Hypnotherapy for Children With Functional Abdominal Pain or Irritable Bowel Syndrome: A Randomized Controlled Trial

1. David Gottsegen, MD* 1. *Department of Pediatrics, Tufts University School of Medicine, Baystate Medical Center, Springfield, Mass. Recurrent or chronic abdominal pain is a common and often perplexing condition, affecting between 15% and 35% of the pediatric population worldwide. Apley (1) first defined recurrent abdominal pain (RAP) in 1958 as at least three episodes of abdominal pain sufficient to disrupt a child's daily activities over the previous 3 months. At the time of Apley's study, only 5% of cases were found to have an organic cause. With newer diagnostic methods, up to one third of cases of RAP may be found to have organic causes. “Red flags” that might indicate specific organic diseases are: a family history of inflammatory bowel disease, fever, weight loss, night awakening, anemia, bloody stools, and localized tenderness. Most children who do not have specific organic disorders have functional RAP. The causes of functional abdominal pain still are poorly understood but are believed to be due to autonomic dysfunction or visceral hypersensitivity to stimuli such as intestinal bowel gas, an acute trigger such as a viral gastroenteritis, an increased central perception of pain, and altered bowel habits such as constipation. Perception of pain is mediated by temperamental, cultural, and psychological factors, such as anxiety or depression, and social stressors, such as learning difficulties and family stress. Functional abdominal pain may be categorized into four specific disorders, as described by the Rome III criteria for functional gastrointestinal (GI) disorders: functional dyspepsia, functional abdominal pain, irritable bowel syndrome (IBS), and abdominal migraine. Postprandial abdominal pain, with feelings of bloating, gas, or heartburn, is classified as dyspepsia and may be associated with gastroesophageal reflux. IBS is characterized by cramping pain with alteration in bowel movements. Episodic abdominal pain …

Self-Administered Cognitive Behavior Therapy for Moderate to Severe Irritable Bowel Syndrome: Clinical Efficacy, Tolerability, Feasibility

Transient Receptor Potential Vanilloid-4 Has a Major Role in Visceral Hypersensitivity Symptoms

Irritable bowel syndrome (IBS) is a common yet debilitating and chronic condition that consists of disturbances in bowel habits and abdominal pain that is frequently relieved with defecation. While the first line of treatment for IBS is pharmacological treatment, this has been shown to fail, leading to the patient being classified as having refractory IBS. The quality of life (QOL) of these patients is greatly hindered; in this case, there are rarely moments of relief. Additional modalities of treatment have been employed in classical cases of IBS, such as psychotherapy, and research has started to evaluate its effectiveness with refractory IBS. Both cognitive behavioral therapy (CBT) and gut-directed hypnotherapy (GDH) are effective in treating classical IBS as they restructure and bring a state of meditation to the patient, allowing them to work through the symptoms. The question is whether it remains successful in refractory cases. This systematic review was conducted with strict adherence to PRISMA guidelines with an initial inquiry resulting in 28,978 publications through PubMed, ScienceDirect, and ProQuest databases. Through automatic and manual screening processes, articles that were peer-reviewed experimental or observation publications done between 2003 and 2023 were included in this study, resulting in 21 publications. Across all studies evaluating CBT, it was consistently found to be successful in improving symptom severity and frequency, QOL, and extracolonic symptoms such as anxiety and depression. When broken down into delivery methods, minimal contact CBT was found to be just as, if not superior, to standard contact. Within this, telephone-delivered CBT was superior to web-delivered CBT. GDH and biofeedback therapy were found to also significantly improve all domains of IBS with no difference between them. Acceptance and commitment therapy were found only to improve associated symptoms. However, there was no significant improvement in their QOL, whereas integrative group therapy found no significant improvement in any domain. Because IBS is so common and crippling to those affected, its crucial to continuously improve QOL through advancement in treatment modalities. Further research should focus more on other modes of therapy as success has been shown in standard therapeutic techniques.

Covering the Cover

Irritable bowel syndrome (IBS), is a common multifactorial gastrointestinal disorder linked to disturbances in the microbe gut-brain axis. Cognitive behavioral therapy (CBT), in face-to-face format has showed promising results on IBS and its associated psychological symptoms. The present study explored for the first time if CBT for IBS affects the autonomic nervous system (ANS) during experimentally induced visceral pain and cognitive stress, respectively. The levels of state and trait anxiety, current and perceived stress were also evaluated. In this uncontrolled trial, individual CBT was performed in face-to-face format for 12 weeks in 18 subjects with IBS. Heart rate variability and skin conductance were measured during experimentally induced visceral pain and during a cognitive task (Stroop color-word test), before and after intervention. The levels of state and trait anxiety as well as self-rated current and perceived stress were also measured before and after the intervention. CBT did not affect ANS activity during experimentally induced visceral pain and cognitive stress. The sympathetic activity was high, typical for IBS and triggered during both visceral pain and cognitive stress. The levels of state and trait anxiety significantly decreased after the intervention. No significant changes in self-rated current or perceived stress were found. Results suggest that face-to-face CBT for IBS improved anxiety- a key psychological mechanism for the IBS pathophysiology, rather than the autonomic stress response to experimentally induced visceral pain and cognitive stress, respectively. This study indicates that IBS patients present high levels of stress and difficulties coping with anxiety and ANS activity during visceral pain and a cognitive stress test, respectively. These manifestations of IBS are however not targeted by CBT, and do not seem to be central for the study participants IBS symptoms according to the current and our previous study. Face-to-face CBT for IBS, it does not seem to affect modulation of ANS activity in response to induced visceral pain or cognitive stress. Instead, face-to-face CBT decreased levels of state and trait anxiety. Implications for further studies include that anxiety seems to be important in the IBS pathophysiology, and needs further scientific attention. This is in line with the fear-avoidance model which suggests that anxious responses to pain and discomfort drive hypervigilance to, and (behavioral) avoidance of, symptom provoking stimuli and vice versa. Catastrophic cognitions, hypervigilance and avoidant behavioral responses are proposed to produce vicious circles that withhold and exacerbate pain-related symptoms and disability, and lead to lower quality of life. Larger scale studies of potential autonomic changes are needed in order to elucidate which mechanisms elicit its effects in face-to-face CBT for IBS, and provide new avenues in understanding the pathophysiology of IBS.

1. Alycia Leiby, MD*,† 2. Minal Vazirani, MD‡,¶ 1. *Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, Goryeb Children’s Hospital, Atlantic Health System, Morristown, NJ. 2. †Department of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA. 3. ‡Siegler Center for Integrative Medicine, Barnabas Health ACC Barnabas Health System, Livingston, NJ. 4. ¶Rutgers – New Jersey Medical School, Newark, NJ. Irritable bowel syndrome (IBS) occurs commonly in pediatrics, with the prevalence estimated at 6% to 14%. (1)(2) The Rome criteria define pediatric IBS as abdominal pain that improves with defecation and/or onset associated with a change in frequency or form of stool. (3) In addition, no evidence of an inflammatory, anatomic, metabolic, or neoplastic process explains the symptoms. The cause of IBS is attributed to a combination of factors, including an altered gut microbiome, low-grade mucosal inflammation, visceral hypersensitivity, abnormal motility, psychosocial stressors, and genetic predisposition. (4) Recognition of these factors serves as the foundation for the biopsychosocial approach to treating pediatric IBS. A successful treatment plan starts with a strong patient-parent-physician relationship in which the child’s pain is validated and the physician compassionately approaches the distress that IBS can cause. Multiple studies have shown that children with IBS have a lower quality of life (QOL) that is comparable to that seen with nonfunctional gastrointestinal conditions. (2)(5) Conventional treatment includes education and reassurance, cognitive behavioral therapy (CBT) for some patients, and consideration of antispasmodic or antidepressant medications. In practice, the lack of strong evidence, potential for adverse effects, and parental concern limit the utility of conventional pharmacologic options. Complementary and alternative medicine (CAM) use in pediatric gastroenterology is common and higher in patients with IBS than nonfunctional gastrointestinal conditions. (6) This article reviews the evidence for CAM therapy in IBS based on adult and pediatric data available in the English language. The World Health Organization defines probiotics as “live micro-organisms which, when administered …

Novel insights which may translate into treatments for irritable bowel syndrome

5-hydroxytryptamine, ulcerative colitis, and irritable bowel syndrome: molecular connections

Objective: This review examines the efficacy of psychological interventions in the management of Irritable Bowel Syndrome (IBS). Methods: In the current study, a comprehensive analysis of the existing literature, covering case studies and clinical trials, compiled from Google Scholar, Sci-Hub, and PubMed, was performed. The research focused on the complex interplay between psychological factors and irritable bowel syndrome (IBS), particularly the ways in which mental and emotional states can impact IBS symptoms and the effects of behavioral therapy on IBS management. Results: The efficacy of psychological therapies in addressing irritable bowel syndrome (IBS) has proven effective. Cognitive Behavioral Therapy (CBT) treats pain perception and gastrointestinal symptoms, whereas gut-directed hypnotherapy is known for lowering symptoms and enhancing quality of life. Mindfulness- based stress reduction and relaxation practices are effective for stress management, but their availability is restricted. Personalized treatment strategies tailored to individual requirements are vital for enhancing the advantages of these therapies in IBS management. Conclusion: Psychological interventions provide a valuable and effective approach to managing IBS. CBT, gut-directed hypnotherapy, and MBSR have been shown to significantly improve symptoms and quality of life. Future research should focus on improving these therapies to better address individual symptoms and brain-gut connections. Incorporating neurological and neurophysiological approaches may improve understanding and lead to more tailored treatments. Expanding accessibility and encouraging collaboration between healthcare providers and mental health specialists will be vital for optimizing IBS management and improving patient outcomes.

Irritable bowel syndrome (IBS) patients often present psychoform symptoms or psychiatric disorders. Among the psychological factors studied in IBS patients, two seem to influence mostly its severity: catastrophizing and somatization. Somatization is an independent risk factor for IBS. In addition, somatization more than the severity of IBS influences the way the patients perceive their illness, the outcome and the efficacy of treatment. Irritable bowel syndrome patients demonstrate greater catastrophizing scores than controls, and pain catastrophizing is a significant predictor of gastrointestinal symptoms related to pain. In this context we analysed the data regarding the efficacy of two psychological treatments in IBS: cognitive behavioral therapy and hypnosis. Cognitive behavioral therapy is focused on replacing maladaptive coping strategies with more positive cognitions and behaviors. Several studies showed that cognitive behavioral therapy is effective in reducing bowel symptoms in IBS, both post-treatment and short-term follow-up. Gut-directed hypnotherapy has beneficial short-term effects in improving gastrointestinal symptoms of patients with IBS, and the results are maintained after one year in half of the patients. Psychological treatments are a suitable option for selected IBS patients.

Efficacy of behavioural therapies for irritable bowel syndrome: a systematic review and network meta-analysis.

Altered central processing, abnormal gastrointestinal motility and visceral hypersensitivity may be possible major pathophysiology of irritable bowel syndrome (IBS). These factors affect each other and are probably associated with development of IBS symptoms. It has been confirmed that lower pain threshold to colonic distention was observed in most of patients with IBS than healthy subjects. We have investigated pain perception of the descending colon among different subtypes of IBS. There was no difference in pain threshold to colonic distention between IBS with diarrhea and constipation. Some brain regions such as the anterior cingulate cortex (ACC) may play a major role for generating pain and/or pain-related emotion in humans. IBS patients showed greater activation in the perigenual ACC during painful rectal distention compared with healthy subjects. Inflammation, stress and the combination of both stimuli can induce significant increase in visceral sensitivity in animal models. Serotonin (5-HT) can modulate visceral perception. It has been thought that 5-HT(3) receptors may play an important role for conveying visceral sensation from the gut. Corticotropin-releasing hormone (CRH) may also modulate visceral pain hypersensitivity in IBS. CRH receptor-1 antagonist significantly prevented an increase in gut sensitivity in rats. It has been demonstrated that non-specific CRH receptor antagonist α-helical CRH significantly reduced abdominal pain score during gut stimulus in patients with IBS. In conclusion, visceral hypersensitivity is common in IBS patients and probably plays a major role in development of the symptoms and both central and peripheral factors may enhance the pain sensitivity.

Manipulation of the Microbiota for Treatment of IBS and IBD—Challenges and Controversies