CityDietitians have teamed up with health psychologist Dr Sula Windgassen to discuss cognitive behavioural therapy (CBT) in the management of irritable bowel syndrome (IBS).
CBT for IBS is a specific protocol of cognitive behavioural therapy tailored for IBS. There is an extensive evidence base demonstrating that CBT for IBS can improve symptom severity and quality of life, and reduce IBS-related anxiety.
The therapy involves providing comprehensive information about the digestive system, the gut-brain axis, and how different biological, psychological and social factors interact to cause and maintain symptoms in IBS. People with IBS experience dysregulation in their colon, which can cause gas, pain, bloating and changes in bowel movements. A subsection of people with IBS may also have increased gut sensitivity, which partially accounts for symptoms.
As people become familiar with these processes, they develop their own personal “vicious cycle of IBS”, identifying factors that maintain their gut dysregulation. CBT protocols gradually work by making changes to decrease gut dysregulation and reduce bowel-related concerns. Wider activity patterns also play a role in IBS, as do more broader thinking patterns. It is common for people with IBS to have high standards and push themselves hard. CBT for IBS can also come to address these beliefs and tendencies.
Turning to CBT for IBS
The guidelines from the National Institute for Health Care Excellence (NICE) recommend CBT for IBS as a tertiary treatment option after first-line medications and/or lifestyle changes, and subsequently the low-FODMAP diet. However, ideally with more practitioners trained in CBT for IBS, people would see benefit from seeking this treatment early on in their symptom experience. In the qualitative feedback for the Assessing Cognitive behavioural Therapy for IBS (ACTIB) study, participants often reported wishing that they were told this information sooner.
CBT for IBS is not compatible with the exclusion phase of the low-FODMAP diet, as it incorporates the reintroduction of avoided foods and seeks to minimise food avoidance. It is also important to have excluded other potential causes for symptoms such as coeliac disease, Crohn's or colitis.
Who might benefit more (or less) from CBT for IBS?
There is currently minimal research in this area. Data from the ACTIB study did not find any distinct patient populations that benefited more or less than others. As the CBT model is tailored to each individual's biopsychosocial experience, it is theoretically highly suitable and effective for all those with IBS, as long as they are receptive to trying an alternative approach. As with all active therapeutic approaches like CBT, it requires a commitment to home practice. For some people, it may not be the right time to commit to that.
Research looking at the efficacy of CBT for IBS is mostly based on protocols spanning between 6-12 sessions (or over a 3-6 month period), with sessions generally lasting between 30-60 minutes. Results from studies suggest that people can start to see significant improvements in symptoms within 12 weeks and that these improvements maintain up to 24 months later (1). More research is needed to assess whether more sessions result in greater improvements for longer.
The nature of CBT for IBS means that individuals are equipped with the knowledge and skills to adapt to future flare-ups, helping them continue to manage symptoms on a long-term basis.
Accessing CBT for IBS
Online vs Face-to Face: A lot of the research assessing the efficacy of CBT for IBS has been in the context of remote delivered CBT, including the largest randomised controlled trial to date of CBT for IBS (the ACTIB study). Generally speaking, research seems to suggest that there is no difference in efficacy of therapy remote versus in person.
Group vs One-to-One: The most recent systematic reviews do not find substantial differences between group vs individual therapy; what is important is what fits the individual. There are pros and cons of each; in IBS, the group aspect can be particularly helpful at dismantling a sense of isolation and stigma that people with IBS often feel. In one-to-one therapy, you have a chance to explore specific challenges that are more personal to you. Both methods work very well.
Finding a Reputable CBT Therapist for IBS
Unfortunately, only a minority of those trained to deliver CBT and accredited with the British Association for Behavioural & Cognitive Psychotherapies (BABCP) will also be trained to deliver CBT for IBS. The easiest way to find someone trained in this is to look at the Rome Foundation Psychogastroenterology website to find a practitioner. Some CBT therapists working in Improving Access to Psychological Therapies (IAPT) services (primary care mental health services in the NHS) will have received long term conditions training, which should have covered the CBT for IBS protocol. If in doubt, ask your practitioner about their training, the amount of patients with IBS they have worked with and general experience with gastrointestinal disorders.
For more information about CBT for IBS, or to book an appointment / course with Dr Windgassen, head to her website.
For dietetic support in the management of IBS, you can book an appointment with one of our specialist dietitians: Sophie Medlin, Dr Bridgette Wilson or Pooja Dhir.
To enquire about ‘The Gut Approach Programme’, our food & mood programme run by our founder, Sophie Medlin & Dr Rabia (Gut Doctor, Hypnotherapist & Yoga Teacher): email@example.com
Dr Windgassen has specialist knowledge using evidence-based psychological approaches for people with persistent physical symptoms and chronic illnesses. Her PhD focused on the therapeutic mechanisms of Cognitive Behavioural Therapy (CBT) in irritable bowel syndrome (IBS). Dr Windgassen’s thesis was based on data from the largest randomised controlled trial of CBT for IBS to date, the results of which have been published in the British Medical Journal and The Lancet Gatroenterology and Hepatology.
References 1. https://pubmed.ncbi.nlm.nih.gov/31492643/