IBS Services

The problem of IBS is best understood by drawing from theories of mind, brain and body in their context.  Interventions for IBS can then be multidimensional and multileveled, to work with the problem connections from many different points of entry.  The integration of these states brings approaches for integrative treatments.  IBS is considered a classic FOOD/MOOD disorder, with multidimensional treatment approaches necessary to fully resolve the condition and restore quality of life.

Treating IBS – Even without fully understanding the causes of IBS, dietary recommendations and techniques for reducing stress, along with the use of medications for specific symptoms have been shown to be very effective. Since both diet and stress can be managed (with support) by many patients, having some control over IBS has proven psychologically helpful.  Strategies include shifting towards whole foods, plant-based diet, adding more fiber, avoiding certain foods, the use of prebiotic and probiotic supplements, drinking lots of water, and following a moderate exercise program which includes yoga and meditation.  Learning how to manage anxiety and the role of cognitions in IBS through psychological counseling has been shown in clinical studies to be very effective.  It should be noted that not all of these strategies are empirically based, but the most powerful research backs certain dietary strategies, medication management, psychotherapy, meditation/relaxation/hypnotherapy/yoga techniques, and the use of Chinese herbs, pre-and-probiotics, and Peppermint Oil therapy.

Psychotherapy and stress management- Psychological factors in general and cognitive processes, in particular, play an important role in the onset, expression and outcome of IBS patients, especially those with “severe” IBS.  Studies show that IBS patients as a group tend to label gut sensations negatively and show a lower tolerance for gut sensations.   A high rate of psychiatric co-morbidity (especially anxiety disorders) is seen among treatment seeking IBS patients.  Given the 6.5 year average time to medical diagnosis for the average IBS patient, a psychological component is likely.  It is not clear which comes first:  the anxiety (and sometimes depression) or the GI problems.  Researchers now believe that evidence shows that mental illness does not cause IBS, but if a patient has anxiety and depression, they are more likely to have or be concerned about IBS symptoms.  And, severe IBS symptoms affect mental health.

Yoga and IBS- The smooth functioning of digestion depends on the action of the autonomic nervous system, especially the parasympathetic branch (PNS), associated with relaxation and restoration.  Stress activates the sympathetic side (SNS), the fight or flight system, which can interfere with the bowels.  Exercise is known to lower stress levels.  Beyond this general effect of physical activity, specific yoga postures can offer help with a wide variety of IBS symptoms.  For example, people with constipation often benefit from gentle yoga stretches and twists, and if they are able, more vigorous poses like Sun Salutations and inversions.  Since stress can lead to both constipation and diarrhea, a variety of practices from asana to breathing exercises designed to calm down the SNS and shift the balance more toward the restorative PNS side of the equation, can facilitate balanced bowel function.

Serious students of yoga practice meditation techniques along with the physical practices (asana), as well as self-study (svadhyaya).  Self-study encourages figuring out what stressors are at play for the individual student, and whether there is a connection between them and symptoms.  Self-study also involves looking at the link between certain foods eaten and how they make the student feel.  Through self-study, if the student continues to eat the offending foods anyway, yoga suggests looking further to ascertain why that might be.  Keeping a yoga journal which includes diet, yoga practice, IBS symptoms, stressors and any other salient information can be instructive and helpful.

Yoga encourages the study of HOW the patient eats.  Rapid eating can be a contributor to IBS symptoms through the ingestion of air and inadequately chewed food, worsening gas and bloating.  The process of mindful (yogic) eating encourages slowing down, savoring each bite, being in the moment with food and our senses, and relaxing.  Bringing more yogic awareness to the entire process of eating can facilitate relaxation by making it more of a meditation.  The practitioner of yoga also can experience a multitude of other health benefits from adopting a more yogic lifestyle, including choosing healthier foods, limiting caffeine and alcohol, using asana practices as stress management, meditating to improve mood, and tuning in to the physical body in ways that invite symptom management.  Rather than plowing through life, anxiously rushing from one activity to another, inviting more anxiety through IBS flare ups, the practitioner can slow down, learn to say no to outside stressors, and watch anxious thoughts come and go.  A yoga practice is the perfect complement to therapy, meditation, and CAM management of IBS symptoms.

There is some scientific evidence for the benefits of yoga and IBS symptom improvement.  One example is of a RCT of 100 patients with IBS which was conducted in India in 1992 (Kumar, 1992).  Patients were divided into three groups; one group was given traditional drug treatment, one a yoga program, and one a combination of drugs and yoga.  The yoga intervention consisted of asana, pranayama (breathing), kriyas (yogic cleansing techniques), and mediation.  The drug therapy included anti-anxiety drugs, antispasmodics, and fiber supplements.  After two weeks of training, the groups were asked to practice 30 minutes per day for the next two months.   Both drugs and yoga used alone were effective in significantly reducing abdominal pain, constipation, diarrhea, anxiety, and other symptoms, with yoga generally more effective the medication.  The combination of yoga and modern drug therapy was consistently more effective than either modality alone, eliminating all symptoms within six weeks, with the benefits persisting at the conclusion of the study.

Due to the low risk of complications, the extensive benefits that yoga provides, as well as overall improvements in self-efficacy and body awareness which accompany a regular yoga practice, IBS patients would benefit from the development of a regular yoga practice tailored for IBS, designed by a competent, certified instructor.  Evidence based, researched yoga protocol for IBS can be found HERE.

Yoga also helps with anxiety in a number of ways.  It offers specific techniques that can reduce symptoms, both in the short and longer term.  Because of its focus on tuning in to inward states, yoga can also help one get beneath the surface of anxiety to figure out what is triggering it, including habitual though patterns or unresolved conflicts.  One of the key yogic techniques used to counter anxiety is to focus on the breath.  The connection between the mind and the breath is most obvious with anxiety.  When one is engaged in anxious, fearful, or stressful states, breathing is changed in a number of ways.  It can become choppy, restrained, shallow, rapid, or even stop altogether for periods of time.  In a calm state, breathing is smooth and rhythmic.

Yoga’s focus on deep abdominal breathing, which focuses on slower, more relaxed patterns, helps the anxious client.  Ironically, lifetime patterns of anxiety can lead to muscle tension restricting the abdominal muscles that circle the belly.  Anytime the belly can’t move freely, breathing is impaired.  Impaired breathing leads to anxiety, and chronic tightness in the intercostal muscles that lie in between the ribs can also impact the breath.  A regular practice of yoga including breath work (Pranayama) is an effective method of combating anxiety, according to scientific studies.  Voluntarily slowing the breath during periods of stress counters many of the physiological components of stress while reducing feelings of anxiety.  Techniques include increasing the length of exhalation relative to the inhalation, relaxed, diaphragmatic breathing, and other practices.

References:

Am J Clin Nutr. (1997). Am J Clin Nutr. Am J Clin Nutr, 66:1006-1010.

Am J Epidemiol. (2008). Am J Epidemio. Am J Epidemio, 168:289-297.

American Psychiatric Association. (1994). Diagnostic Criteria from DSM-IV. Washington DC: Am Psychiatric Association.
Anxiety and Depression Association of America. (2012, May 20). Irritable Bowel Syndrom. Retrieved from Understanding the Facts: http://www.adaa.org/understanding-anxiety/related-illnesses/irritable-bowel-syndrome-ibs
Asheville Hypnosis. (2012). What the AMA and Others say about Hypnotherapy. Retrieved from What is Hypnotherapy: http://www.ashevillehypnosis.com/serv05.htm
Bensoussan A, T. N. (1998). Treatment of Irritable Bowel Syndrome with Chinese herbal medicine: a randomized controlled trial. . JAMA, 1585-9.
Blanchard EB, M. H. (1996). Psychological Treatment of Irritable Bowell Syndrome. Professional Psychology: Research and Practice, 241-44.
Boll, T. J. (2004). Handbook of Clinical Health Psychology (Vol. 1). Washington, DC: American Psychological Association.
Bowen, R. (2006). The Enteric Nervous System. Retrieved from Colorado State.edu: http://www.vivo.colostate.edu/hbooks/pathphys/digestion/basics/gi_nervous.html
Brown University. (2012, May 20). Laxative Abuse. Retrieved from Brown University: http://www.brown.edu/Student_Services/Health_Services/docs/Laxative%20Abuse.pdf
Camilleri, C. &. (1997). Review Article: Irritable bowel syndrome. Alimentary Pharmacology and Therapeutics, 11, 3-15.
Cappello G, S. A. (2007). Peppermint Oil (Mintoil) in the treatment of irritable bowel syndrome. Digestive and Liver Disease, 39:530-536.
Cappo BM, H. D. (1984). The utility of prolonged respiratory exhalation for reducing physiological and psychological arousal in non-threatening and threatening situations. J Psychosomat Res., 265-273.
CHPA. (2012, May 16). Consumer Health Products Association. Retrieved from Sales by Category of OTC medications: http://www.chpa-info.org/pressroom/Sales_Category.aspx
Clark DM, S. P. (1985). Respiratory control as a treatment for panic attacks. J Behavo Ther Exper Psychiat, 22-30.
Coates MD, M. C. (2004). Molecular defects in mucosal serotonin content and decreased serotonin reuptake transporter in ulcerative colitis and irritable bowel syndrome. Gastroenterology, 126:1657-1664.
DA Drossman, F. C. (1999). Psychosocial Aspects of Functional Gastrointestinal Disorders. Gut, 1125-1130.
Dr Mueller-health psychology.com. (2008, November 17). The Brain Gut Connection. Retrieved from Drmueller-healthpsychology.com: http://www.drmueller-healthpsychology.com/f/The_Brain-Gut_Connection.pdf
Emmanuel, A. (2011). Current Management Strategies and therapeutic targets in chronic constipation. Ther Adv Gastroenterol, 1177.
Fayyaz M, L. J. (2008). Serotonin receptor modulators in the treatment of irritable bowel syndrome. Ther Clin Risk Manager, (1) 41-48.
Gaylord SA, P. O. (2011). Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized controlled trial. American J Gastroenterol, 1678-88.
Hamilton Miller, J. (2001). Probiotics in the Management of Irritable Bowel Syndrome: A Review of Clinical Trials. Microbial Ecology in Health and Disease.
Harriet Brown. (2011, October 11). The Other Brain also Deals with Many Woes. Retrieved from The New York Times: http://www.nytimes.com/2005/08/23/health/23gut.html?pagewanted=all
Heitkemper MM, C. K. (2011). Is childhood abuse or neglect associated with symptom reports and physiological measures in women with irritable bowel syndrome? Biol Res Nurs, (4): 399-408.
IFFGD. (n.d.). International Foundation of Functional Gastrointestinal Disorders. Retrieved from About IBS.org: http://www.aboutibs.org
ISAPP. (2012, May 20). Probiotics: A Consumer Guide for Making Smart Choices. Retrieved from International Scientific Association for Probiotics and Prebiotics: http://www.isapp.net/docs/Consumer_Guidelines-probiotic.pdf
Jongsma A, P. L. (2006). The Complete Adult Psychotherapy Treatment Planner. Hoboken: John Wiley & Sons.
Kumar, V. (1992). A study on the therapeutic potential of some hatha yogic methods in the management of IBS. The Journal of the International Association of Yoga Therapists, 3:25-38.
Lackner, P. J. (2005). No Brain, No Gain: The Role of Cognitive Processes in Irritable Bowel Syndrome. Journal of Cognitive Psychotherapy: An International Quarterly, 125-136.
McCall, T. (2007). Irritable Bowel Syndrome. In T. McCall, Yoga as medicine: the yogic prescription for health and healing (pp. 427-442). New York: Bantam.
Monash University, E. (2011). The Low FODMAP diet: reducing poorly absorbed sugars to control gastrointestinal symptoms. Victoria, Australia: Monash University.
Mykletun A, J. F. (2010). Prevalence of mood and anxiety disorder in self reported irritable bowel syndrome (IBS). An epidemiological population based study of women. BMC Gastroenterology.
Park HJ, J. M. (2008). Psychological distress and GI symptoms are related to severity of bloating in women with irritable bowel syndrome. Res Hurs Health, 31:98-107.
Sabater-Molina M, L. E. (2009). Dietary fructooligosaccharides and potential benefits on health. Physiol Biochem, 315-28.
Shepherd Works. (2012, May 19). Low FODMAP diet. Retrieved from Shepherd Works: http://shepherdworks.com.au/disease-information/low-fodmap-diet
Shepherd, P. G. (2010). Evidence Based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology 25, 252-258. Retrieved from Shepherd Works.
Simpkins A, S. C. (2011). Meditation and Yoga in Psychotherapy: Techniques for Clinical Practice. Hoboken: John Wiley & Sons.
Sykes, M., Blanchard, E., & Lackner, J. (2003). Psychopathology in Irritable Bowel Syndrome: Support for a Psychophysiological Model. Journal of Behavioral Medicine, 361-372.
Tameja I, D. K. (2004). Yogic versus conventional treatment in diarrhea-predominant irritable bowel syndrome: a randomized control study. Appl Psychophysiol Biofeedback, 29:19-33.
Tavassoli, S. (2009). Yoga and the management of IBS. International Journal of Yoga Therapy, 97-103.
The Rome Foundation. (2012, May 20). Rome Foundation: To Improve the lives of people with Functional GI Disorders. Retrieved from Rome Criteria: http://www.romecriteria.org/about/
Tilburg M, P. O. (2008). Complementary and Alternative Medicine Use and Cost in Functional Bowel Disorders: A six month prospective study in a large HMO. BMC Comp Alt Med.
Toner B, S. Z. (1999). Cognitive Behavioral treatment for irritable bowel syndrome. New York: Guilford Press.
University of Massachusetts. (2012, May 20). Stress Reduction Program. Retrieved from Center for Mindfulness, Health Care, and Society: http://www.umassmed.edu/cfm/stress/index.aspx
Up to Date. (2012, May 20). Patient Information: Irritable Bowel Syndrome: Beyond the Basics. Retrieved from Up to Date : www.uptodate.com/contents/patient-information-ritable-bowel-syndrome-beyond-the-basics?view=
Welliver, N. (2012, May 20). The Importance of Chewing. Retrieved from Bastyr Center for Natural Health: www.bastyrcenter.org/content/view/1066
World Gastroenterology Global Guidelines. (2011). Probiotics and Prebiotics.
Yoon S, G. O. (2006:16:2). Management of Irritable Bowel Syndrome in Adults: Conventional and CAM approached. Alternative Medicine Review, 132-151.

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