Why Psychological Therapies Can Benefit Individuals with Gut and Digestive Problems
The brain-gut connection is also known as the Brain-Gut Axis, and it is very fascinating. The interesting fact about the gut (digestive system) and brain, is that it is said to develop in the same area of tissue in the embryo. As the embryo grows, the brain migrates to the top end, while the majority of the gut, the other end. It is important to remember however, the digestive tract begins in the mouth and end in the bottom. Because they develop from the same area of tissue, they share similar neurotransmitters (communication molecules). The most well-known being dopamine, GABA and serotonin. One of the roles of neurotransmitters is to create communication between the brain and the gut. Dopamine is suggested to control the brains pleasure and reward centers, while serotonin has been suggested to be an important neurotransmitter that is responsible for appetite and digestion as well as positive mood, social behaviour, memory and sleep. What’ s interesting is that approximately 85% of serotonin is located in the gut lining.
An additional fascinating feature of the gut is that it contains just as many nerves cells as the spinal cord does. In fact, it has its own nervous system, the Enteric Nervous System (ENS). The ENT works with the Central Nervous System (CNS or Brain), however it can also work independently of it. The role of the ENT is to coordinate and control gastrointestinal functions including secreting digestive juices, motility (movement of digested food) and moving mucus throughout the digestive tract. The ENT is also responsible for the blood flow vital for normal digestive processes.
The ENT and the CNS come together to form the Brain-Gut Axis. Communication between the CNS and ENT is bidirectional, suggesting that the brain/mind affects the gut, and vice-versa.
A new and exciting are of research is in the Gut-Microbiota. There are over 100 trillion gut microbes in the gut that mediate communication though the hypothalamic-pituitary-adrenalin axis (HPA). Although the research is still in its infancy, animal studies have shown the gut microbiome may influence emotions and vice versa.
How do emotions affect the gut
Our digestive system and emotions are closely tied. It is not uncommon for us to use our digestive experiences to describe the way we feel. For example: ‘that was gut wrenching’, ‘I feel sick to my stomach’, and ‘I have butterflies in my stomach’, to name a few!
As discussed, brain-gut communicate via neural pathways, however they also communicate via immune and endocrine mechanisms. The Hypothalamus is considered to be an old brain structure within our CNS, who’s role is to maintain physiological homeostasis as well as regulating autonomic and neuroendocrine function in the body. The Hypothalamus is also considered to be part of the limbic system (also includes amygdala, medial thalamus and anterior cingulate cortex), also referred to as the visceral or emotional part of the brain, therefore its other role is to mediate emotional responses.
Emotional and psychological distress and the Brain-Gut Connection
When we are stressed our brain is perceiving a potentially threatening situation. This threat response activates the sympathetic nervous system that activates the release of adrenalin and noradrenalin into the body. This causes the blood vessels in the major muscles the dilate in order to provide more blood, nutrients and oxygen to the muscles to help the individual either run away or fight (the well-known fight or flight response). This causes our bodies to heat up, which is why we sweat during episodes of fear or anger. Our body needs to cool down. In order to get the blood to the muscles quickly, the heart beats faster and our breathing becomes quicker in order to supply oxygen and remove carbon dioxide from the body. Although there are other changes occurring in the body, these are the most commonly noticeable.
When we are in fight/flight, our digestive system slows down in order to divert the blood and energy to the muscles of the body.
Stress also releases a hormone called corticotrophin releasing factor (CRF). Corticotrophin releasing factor has a direct effect on the digestive system. It increases the sensitivity of the gut, delays gastric emptying of the stomach and increases the motility (movement) of the bowel resulting in increased defecation. This is the normal response of the digestive system. For various reasons, some not completely known, individuals with Functional Gastrointestinal Disorders (FGIDS) have visceral hypersensitivity, which means that their gut is more sensitive and therefore more likely to react more strongly to the physiological changes caused by CRF.
Psychological distress has also been found in studies to increase inflammatory markers in the blood and increase gastrointestinal permeability (leaky gut).
Functional Gastrointestinal Disorders (FGID’s)
With any tummy problem, it is always important to visit your doctor or treating specialist to exclude any pathology that might be life threating. Functional gastrointestinal disorders are disorders where no identifiable pathology has been found through diagnostic testing, however the individual is still experiencing symptoms. Therefore, this does not mean that the individual is creating the problem or faking it.
The exact causes of FGIDS including Irritable Bowel Syndrome (IBS), is still unclear. It has been suggested that the causes may be multifactorial, and are therefore better explained by a biopsychosocial model. A biopsychosocial model implies complex interactions between the brain, the gut, and genetic and environmental factors.
The most common functional disorders (defined by ROME III Criteria) include:
- IBS: Is a group of gastrointestinal symptoms, including recurrent abdominal pain, functional bloating, functional constipation, functional diarrhoea and unspecified functional bowel disorder.
- Functional dyspepsia: Feeling of fullness, early satiation, epigastric (upper tummy) pain and epigastric burning
- Rumination: Regurgitation of recently ingested food into the mouth that is persistent and recurrent.
- Gastroesophageal disorder (GORD): Contents of stomach coming back up oesophagus due to lower oesophageal sphincter not closing properly.
- Gastroparesis: Delayed gastric emptying resulting from movement of stomach muscles (motility) not functioning normally.
- Chronic Idiopathic Nausea: Nausea at least several times per week.
- Functional abdominal pain: Continuous or nearly continuous abdominal pain
- Functional Vomiting: one or more vomiting episodes per week.
- Aerophagia: Repetitive belching due to swallowing air.
- Abdominal migraine: intense acute periumbilical pain.
- Cyclic vomiting syndrome: Two or more period of retching and unremitting vomiting lasting hours to days.
- Incontinence: Recurrent uncontrolled passage of faeces.
Even though a cause for the symptoms is not always found, this does not mean that you cannot treat or manage the digestive problems. Psychological therapies have been found in a substantial number of clinical research studies to help.
Psychological therapies for Gut problems
Psychological therapies have been extensively shown in validated research trials to be helpful in managing FGID’s in adults and children. These therapies include Gut Directed Hypnotherapy, Cognitive Behavioural Therapy (CBT) and Mindfulness.
Aims of Psychological therapies
- To reduce abdominal pain and symptoms
- Help reduce medications
- To reduce anxiety
- Improve mood
- Help return to work
- Improve self-confidence, especially around food and social situations
- Help individuals get back in control of their lives.
What Therapies can benefit individuals with Gut problems?
1. Gut-Directed Hypnotherapy (GDH)
Hypnotherapy as a treatment is nothing new. It can be traced back to ancient Egypt’s ‘sleep’ therapy rooms. In more modern times, i.e., in the late 1800’s it was used as an anaesthetic for surgery by the surgeon Dr James Braid, before the advent of chemical anaesthesia. Since that time, Hypnotherapy has been utilised for treating anxiety, phobia and even medical conditions.
Unfortunately, the therapeutic benefits of hypnotherapy have been tainted by theatrical shows depicting hypnotised individuals not being in control. This is incorrect. It has been shown that medical clinical hypnotherapy and ‘stage’ hypnosis are completely different. In clinical hypnotherapy, individuals are shown how to get in control of their bodies, not to lose control.
Gut-Directed Hypnotherapy originated in Manchester in England in the early 1980’s by Prof Peter Whorwell, a Professor of Gastroenterology and specialist in IBS at Wythenshawe hospital. It is believed that Prof Whorwell was not completely satisfied with medications in the treatment of IBS at the time and together with his interest in hypnotherapy, thought to try and see if it helped his patients. Prof Whorwell was reported to be impressed by what he was seeing that he conducted a research trial, finding that approximately 70 % of his patients improved. He published this study in the Lancet in 1984, one of the most prestigious medical journals in the world. Since that time, Prof Whorwell set up the first gut directed hypnotherapy unit in Manchester Wythenshawe hospital. He and his team went to on to conduct multiple studies involving the benefits of the treatment, all of them finding a significant reduction in the symptoms of FGID’s as well as an overall improvement in quality of life. This meant patients experienced a reduction in medications, quicker return to work or normal functioning as well as a reduction in anxiety and improvement in mood.
Gut-Directed Hypnotherapy has been replicated multiple times around the world with similar findings, 70-80% of individuals improve. Prof Whorwell and his team also conducted a follow up audit study where they followed up patients that had completed treatment 5 years earlier. The study found of the 80% that had improved, 80% of them had maintained the positive outcome 5 years post treatment completion.
There are three main areas of study that have shown GDH to change the functioning of the digestive system and brain. One of the studies found GDH to reduce the sensitivity of the digestive tract, another found that it influenced motility, i.e. reduced diarrhoea and improved constipation. The effect of hypnotherapy of pain in IBS has also been studied. One particular research study found that people with IBS have a sensitive Anterior Cingulate Cortex (shown under functional MRI to be brighter), the centre in the brain that interprets pain as pain (also part of the limbic system). Post hypnotherapy, results showed a reduction in sensitivity (less bright) and hence a reduction in perceived pain.
The effectiveness of GDH in and adults and children has also been thoroughly studied and published in multiple gastrointestinal journals. The results have found again that approximately 70% of children improve.
The benefit of this treatment with children is that it does not carry with it any negative side effects, i.e., the treatment will not interfere with other systems in the body.
2. Cognitive Behavioural Therapy (CBT)
Cognitive behavioural therapy (CBT) is one of the most studied techniques involving a mind–body intervention for reducing the symptoms of IBS. It also utilises the brain-gut axis to help individuals reduce the symptoms and distress associated with their condition.
Cognitive behavioural therapy aims to identify patterns of behaviour and thinking that lead to negative emotions that can contribute to the digestive problem. These emotions can sometimes hinder progress toward desired life goals.
The aim of CBT is to identify negative ‘inaccurate’ thoughts that result in emotional distress and ultimately contribute to avoidant behaviour and an increasing digestive symptoms.
3. Mindfulness Therapy
Mindfulness therapy is a psychological therapy that uses mindfulness/meditation or present moment awareness to help individuals manage/reduce their psychological distress. It has been extensively studied, and found to help reduce symptoms and psychological distress in individuals experiencing pain and gastrointestinal problems. Mindfulness therapy involves helping children to be aware of negative emotions or physical discomforts and to let go of struggle and resistance. Acceptance does not mean resignation or giving up. By accepting, an individual learns how to better tolerate discomfort and negative emotions. Mindfulness practices also involve mediation, which, in itself has been shown to help individuals relax.
About The Author
Dr Jim Kantidakis is an Expert Gut-directed Clinical Psychologist; Clinical Hypnotherapist, and one of the first experts in Australia to use Psychological /Hypnotherapy treatment of individuals diagnosed with gastrointestinal problems. Jim has extensive expertise in the area, with over 10 years of experience. He was also the first Psychologist to provide Psychological and Hypnotherapy treatment to children in paediatric gastroenterology in Australia.
Jim was also the first Australian to travel and undergo training from a leading Gastroenterologist, Prof Whorewell and the founding gut-directed hypnotherapy team in Manchester, UK. He has since been invited to present at several gastrointestinal conferences and events. These include 2 Australian Gastrointestinal conferences, as well as the Australian Neuro-Gastrointestinal and Motility conference, a Continence symposium, and a IBD Nurses education. Jim also provided educational training to Gastrointestinal registrars, also running a workshop on the psychological effects of Ulcerative Colitis to Fresenius Kabi drug representatives in Sydney.
Jim’s passion and keen interest in the area of gastroenterology has inspired him to develop and train his own team of expert Psychologists/Hypnotherapist’s, under ‘The Gut Centre’. The Gut Centre offers psychological / hypnotherapy treatment to help patients significantly reduce the symptoms and psychological distress of IBS and functional digestive disorders, including pelvic pain. Jim has recently submitted his Doctoral Thesis looking at the Psychological factors contributing to psychological distress and quality of life in individuals diagnosed with Inflammatory Bowel Disease. His interest in this area has resulted in him undergoing training at St. Vincent’s Hospital Public IBD Counselling clinic. Jim was so
impressed with the benefits of the counselling program that he opened Australia’s first and only Private IBD Counselling Clinic. Jim has also recently been invited to join the St.Vincent’s Hospital Functional Gut Clinic.
Jim and his team at the Gut Centre continue to provide evidence based psychological interventions, including hypnotherapy treatment, with the highest level of patient care.