Emotional Awareness and Expression Training Reduces Symptom Severity in Irritable Bowel Syndrome

IBS is a functional gut disorder that disturbs the normal functions of the bowel but with no obvious, single cause. The main signs and symptoms of IBS are abdominal pain or discomfort, that is associated with either diarrhoea or constipation or a combination of both. IBS is suspected to be a disorder that involves the dysfunction of the brain-gut-microbiome axis; for some reason the signalling and feedback to and from the brain and the gut is impaired leading to changes in motility, increased nerve sensitivity and comorbid symptoms of depression and anxiety. For a fuller overview of the disorder tune in to the podcast episode all about understanding the illness. Listen here.

It is well documented that people with a diagnosis of IBS tend to experience high levels of psychological stress and/or have experienced traumatic experiences in the past. They are also more likely to have difficulty in intimate relationships and in expressing their feelings. Building on previous research that psychological therapies are an effective treatment for IBS, a new randomised controlled trial investigated the utility of a type of therapy specifically designed to address emotional awareness and expression in people with IBS.

In this study IBS patients were recruited and were then randomly assigned to one of three groups:

1.      Emotional Awareness and Expression Training (EAET)

2.      Relaxation training, which has been shown to be helpful for IBS patients

3.      Waiting list – this was the control group, to compare whether any changes seen in the other two groups would have happened anyway without any intervention.

Both the EAET and relaxation groups received three 50-minute training session delivered over three consecutive weeks i.e. one session a week. They were then assessed two weeks after the end of the last session and then again 10 weeks after that. Participants in groups one and two received a similar explanation about the link between stress and IBS but the EAET group were provided with specific skills to improve emotional expressions such thinking of someone they have a difficult relationship with and being encouraged to describe those feelings out loud as if the person was present. They were later encouraged to express their emotions directly with that person. The relaxation group were coached in muscle relaxation, deep breathing and mindfulness meditation.

Most of the 106 participants in this study were women (IBS is more common in women than men) and had had IBS for more than 20 years. At the end of the 10-week follow-up period 63% of the people in the EAET group reported significant improvements in their IBS symptoms. People in the relaxation and waiting list groups did not report any significant change in the severity of their IBS. Both relaxation and EAET improved the participants’ quality of life. What is striking about this result is that the intervention was very brief, less than three hours in total, and the participants had been ill for many years. The therapists administering the treatment were clinical psychology graduate students. This could mean that, in practical terms, provision of this kind of treatment might be highly cost-effective.

This was a small study with a short follow-up period. It will be important to replicate and extend the research by looking at larger groups and whether the results are sustained over many months. Nonetheless, this paper supports the theory that psychological stress and emotional suppression lead to overstimulation of the stress response and that this dysregulates the nervous communication between the brain and the gut. On an everyday level we recognise this as, for example, feeling so nervous about something that we feel nauseous or have butterflies in our stomachs. In IBS there is  understood to be a continuous over-activation of this system, and the body struggles to return to equilibrium.

Separately, this study also reinforces the importance of acknowledging and expressing emotions rather than ignoring, avoiding or denying them. Unexpressed emotional states don’t just go away, they exert a physiological effect that can lead to somatic symptoms.

As a side note, the researchers’ description of EAET sounds akin to the Distress Tolerance protocols inherent in a type of therapy called Dialectical Behaviour Therapy (DBT), originally designed to help people with a diagnosis of Borderline Personality Disorder to improve how they manage their emotions and their interpersonal effectiveness. There are many Clinical and Counselling Psychologists trained in DBT so this may prove a more accessible route for clients than trying to find an EAET trained therapist.

Reference

Thakur, E. R, Holmes, H. J, Lockhart, N. A., Carty, J. N., Ziadni, M. S., Doherty, H. K., Lackner, J. M., Schubiner, H. & Lumley MA. (2017). Emotional awareness and expression training improves irritable bowel syndrome: A randomized controlled trial. Neurogastroenterology, Epub ahead of print. doi: 10.1111/nmo.13143

Psychotherapy Improves Mental Health and Daily Functioning in Irritable Bowel Syndrome: Meta-Analysis.

Last year I reported on a study that showed that psychotherapy was effective at reducing the physical pain of Irritable Bowel Syndrome (IBS) and that, at the same time, it was superior to medication at reducing healthcare costs associated with the illness. A new meta-analysis extends the work on psychological treatments for IBS and shows that talking therapies are also effective for improving the mental health and quality of life sufferers. Quality of Life is a psychological measure that looks at the wellbeing of an individual or group and can assess how much satisfaction they derive from their lives or from an aspect of it, such as work or relationships. IBS can reduce quality of life by getting in the way of normal daily activities like work or socialising and can create mental distress but, for example, increasing anxiety around eating and meal times, depression and, in severe cases, suicidal thoughts.

This new meta-analysis looked not only at the efficacy of psychotherapy on improving mental health in IBS sufferers but also at which type of therapy was most effective. The researchers collated 31 randomised controlled trials that provided data on overall mental health and daily functioning of nearly 2000 individuals from different countries. The researchers found that all kinds of psychotherapy were effective at improving psychological wellbeing, people felt better. When it came to daily function cognitive behaviour therapy (CBT) appeared to be the most effective, compared to psychodynamic, hypnosis or relaxation therapy.

Whilst this research is encouraging in relation to the value of therapy in treatment of IBS it does present with a number of problems. First, the researchers have been unable to distinguish between what types of CBT were being provided. For example, some ‘brands’ of CBT focus more on mindfulness, whilst others focus on acceptance and behaviour change. It may be that there is further variability within these groups. In addition, CBT was by far the most studied therapy. Looking at mental health, for example, there were 19 CBT trails compared to 3 psychodynamic. More research on other types of psychotherapy will be useful to add strength to the conclusions. Also, another paper published this year suggested that though CBT did lead to improvements in quality of life for IBS sufferers the results did not last long after the therapy ended.

What we can be surer of is that psychological therapy does improve the mental wellbeing of IBS patients and can be an important tool in helping improve their quality of life. Though there is further research required this meta-analysis adds to the body of research highlighting the powerful role that psychological therapies play in IBS treatment.

References

Laird, K. T., Tanner-Smith, E. E., Russell, A. C., Hollon, S. D. & Walker, L. S. (2017). Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis. Clinical Psychology Review, 51, 142-152. https://doi.org/10.1016/j.cpr.2016.11.001

Dehkordi AH, Solati K. The effects of cognitive behavioral therapy and drug therapy on quality of life and symptoms of patients with irritable bowel syndrome. Journal of Advanced Pharmaceutical Technology & Research. 2017;8(2):67-72. doi:10.4103/japtr.JAPTR_170_16.

Exercise (Walking) Increases Effectiveness of CBT in Reducing Depression and Suicidal Thoughts

Depression is now the leading cause of global disease burden. This means that depression is a greater cause of loss of quality of life and days without illness than other illnesses such as heart disease and type 2 diabetes. This week the Mental Health Foundation published a report indicating that only 13% of people in the UK report living with good mental health. More than ever we need to find ways to support mental wellness and increase the efficacy of standard treatment.

I have reported elsewhere research indicating the beneficial effects of physical exercise on mental health. Exercise improves brain function in a number of ways including increasing blood flow to the brain, promoting the growth of new brain cells and increasing levels of serotonin and dopamine, neurotransmitters associated with good mood and satisfaction. A new study compared the effectiveness of Cognitive Behavioural Therapy (CBT), a recognised effective treatment for depression, against a combined treatment package of exercise and CBT for treating depression. In this Iranian study 54 (70 started, 16 dropped out) sedentary people with mild to moderate depression were assigned to either a combined CBT and exercise group or a CBT only group. The CBT was delivered in groups of 4-6 people, one 90-minutes session per week for 12 weeks. Interestingly, and importantly, the exercise was not strenuous or high-impact. It involved:

• 5 minutes of warm up flexibility exercises
• 5 minutes of clapping and light movements
• 20 minutes walking at moderate intensity
• 5 minutes cool down and deep breathing.

This was repeated three times per week for 12 weeks in the evening.

The authors conclude that both groups saw improvements in their depression and reduced suicidal thoughts. However, the combined CBT and exercise group also improved their daily functioning and the combined treatment was superior than CBT alone at reducing depression and suicidal thoughts.

Using exercise as an adjunct to traditional therapy provides a low-cost, safe, easily accessible way to improve the effectiveness of standard treatment that has the added benefit of improving physical health too. This work adds further support to the importance approaching mental health from a whole-body perspective.

Reference

Abdollahi, A., LeBouthillier, D. M., Najafi, M., Asmundson, G. J. G., Hosseinian, S., Shahidi, S., Carlbring, P., Kalhori, A., Sadeghi, H. & Jalili, M. (2017). Effect of exercise augmentation of cognitive behavioural therapy for the treatment of suicidal ideation and depression. Journal of Affective Disorders, https://doi.org/10.1016/j.jad.2017.05.012