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

Effect of Probiotics on Central Nervous System Functions in Animals and Humans: A Systematic Review

Many by now will be familiar with the term ‘friendly bacteria’, referring to the vast population of bacteria in the digestive tract. This population of microbes (the microbiome) play an important role in maintaining our digestive health and many people consume yogurt and other fermented milk drinks to promote gut health. Increasingly research is showing us that the gut microbiome has a significant effect on our mental as well as physical health.

To gain a better overview of the current status of research in this area a systemic review of random controlled trials was conducted and published in the Journal of Neurogastroenterology & Motility. The researchers reviewed 25 animal and 15 human trials. Of the studies involving human participants just over half described significant effects of probiotics on central nervous system function and an intake of probiotics for four weeks appeared to be the threshold for noticeable effects. In the human trials the most common bacterial strains tested were Bifidobacterium longum, B. breve, B. infantis, Lactobacillus helveticus, L. rhamnosus, L. plantarum, and L. casei, all of which are present in fermented foods such as yogurt, kefir and traditional (unpasteurised) sauerkraut.

Looking at both the animal models and human trials the results of this review indicated that probiotics were an effective intervention for a range of mental health disorders including anxiety, depression, Obsessive Compulsive Disorder (OCD) and memory function. A number of potential mechanisms were identified:

• Reduced cortisol (stress hormone) levels

• Reduced inflammation.

• Improved immune function

It is also feasible that some of the known metabolites of the microbiome such as GABA, an inhibitory neurotransmitter, might play a role either via the vagus nerve or more directly by crossing the blood-brain barrier. Whilst the review is generally positive the researchers called for further studies to be conducted with human participants in order to be able to draw firmer conclusions on the promising role of probiotics on mental diseases.

Reference:

Wang, H., Lee, I., Braun, C. & Enck, P. (2016). Effect of Probiotics on Central Nervous System Functions in Animals and Humans: A Systematic Review. Journal of Neurogastroenterology & Motility, 22, 589-605.

The Role of Emotion Suppression in Chronic Fatigue Syndrome

Last month a report on the possible biological mechanisms underlying Chronic Fatigue Syndrome (CFS) generated a lot of interest on social media so I thought I would follow that up with a new study that discusses the psychological and emotional processes of the disorder.

This study from researchers at King’s College London looked at the relationship between emotional suppression and fatigue in CFS. Patients recruited from two specialist CFS services (and healthy controls) were required to watch a distressing film clip. Half of the group were told that they could deal with the emotions from watching the film in any way that they liked and the other half were told that they had to suppress their emotional responses. All were monitored for signs of distress by video-tape and skin conductivity.

Before watching the video participants completed a questionnaire about their beliefs about emotions. This scale is designed to uncover whether people hold unhelpful beliefs, for example that showing emotions is a sign of weakness, that it is important to keep up a brave face or that others will think less of you for expressing your true feelings. Participants also completed a measure of depression and anxiety. After watching the clip participants were asked how fatigued the felt.

The results showed that participants with CFS experienced higher rates of distress but were less likely to express them, even when they were allowed to. This study indicates that this is partly due to self-held beliefs by the CFS group that expression of emotion is unacceptable. Interestingly, all participants in the suppression condition experienced higher levels of anxiety at the end of watching the film.

The researchers also showed an important relationship between emotional suppression and fatigue. When emotions were suppressed the distress didn’t go away but showed up in the body, and this increased physiological distress was associated with higher rates of fatigue. In short: the more suppression the more fatigue.

In addition, people in the CFS group were so efficient at hiding their feelings that observers found it difficult to tell if they were suffering. In the real world this makes it harder for individuals to access support and increases the likelihood of being overwhelmed and isolated.

This paper is important for individuals and professionals dealing with CFS. It highlights the importance of addressing the beliefs about emotions as a way of relieving the symptoms of the syndrome. Psychotherapy and mindfulness-based treatments are an effective way of helping people to stop supressing their emotions and learn how to accept, process and manage them providing hope for the 250,000 people with CFS in the UK.

Rimes, K. A., Ashcroft, J., Bryan, L., & Chalder, T. (2016). Emotional Suppression in Chronic Fatigue Syndrome: Experimental Study. Health Psychology. Advance online publication. http://dx.doi.org/10.1037/hea000034