Ellen C. Joseph, Ph.D.
Licensed Clinical Psychologist
GI Psychology
Tiffany Duffing, Ph.D.
Licensed Clinical Psychologist
Co-Founder & President, GI Psychology
What are Disorders of the Gut-Brain Interaction (DGBIs)?
The gut and brain are constantly in communication through the central (brain and spinal cord) and enteric (gut) nervous systems, which is better known as the gut-brain connection or the gut-brain axis. This communication system is responsible for hunger and satiety cues, as well as informing the brain when something problematic is in the gastrointestinal (GI) system (e.g., a virus). For some people, the gut-brain connection has become sensitized as a result of various precipitating factors, such as an infection, genetics, chronic stressful life events, or constipation/diarrhea. Consequently, these individuals experience visceral hypersensitivity, or the magnification and exacerbation of typical gastrointestinal sensations – this can cause severe abdominal pain, bloating, gas, nausea, or discomfort. The brain then regularly scans for and perseverates on these sensations (i.e., hypervigilance), resulting in a vicious cycle of GI symptoms and psychological distress (Jagielski & Chang, 2021).
GI conditions that are caused by this malfunctioning communication system are called Disorders of the Gut-Brain Interaction (DGBIs), which were previously categorized as functional GI disorders. The Rome Foundation outlines the criteria for DGBIs, which include some combination of motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, or altered central nervous system (CNS) processing (Rome Foundation, n.d.). Based on the most current Rome V Criteria, there are 33 DGBI diagnoses for adults and 17 diagnoses for children (Rome Foundation, n.d.). Some common examples include Irritable Bowel Syndrome (IBS), Functional Dyspepsia, Functional Abdominal Pain, Functional Nausea, and Cyclic Vomiting Syndrome.
Prevalence of DGBIs
DGBIs are more common than most assume – approximately 40% of adults and 24% children meet criteria for a DGBI at some point during their lives (Sperber et al., 2020). Furthermore, research has demonstrated that these diagnoses are a cross-cultural and an international condition. An epidemiological study conducted in 2020 utilized both internet and household surveys to screen for 22 different DGBIs. Data were collected on all continents except Antarctica. Results indicated 40.3% participants from internet surveys and 20.7% from household surveys met criteria for a DGBI, with a higher prevalence in females than in males (46.5% vs. 34.2% for internet surveys, 23.1% vs. 18.3% for household surveys; Sperber et al., 2020).
Notably, common comorbid conditions include trauma, disordered eating, anxiety, and depression. Individuals with a trauma history have reported lower levels of GI-related quality of life and higher levels of distress (Jagielski et al., 2021). Research has also demonstrated high comorbidity between gastrointestinal complications and eating disorders (EDs), including but not limited to postprandial fullness (96%), abdominal distention (90%), and abdominal pain, early satiety, and nausea (50%). Approximately 16% of patients diagnosed with EDs also meet criteria for functional dysphagia (Ferreira, 2023). Additionally, it has been shown that up to 39% of patients with DGBIs also experience anxiety, and 23% experience both anxiety and depression. This relationship is bidirectional, such that chronic anxiety and/or depression can eventually lead to GI distress over time, and a DGBI diagnosis can contribute to new-onset anxiety and/or depression (Staudacher et al., 2023).
Treatment Options for DGBIs
Although DGBIs are impacting communities in very significant ways, too few people are aware that there are effective psychological treatments. Cognitive Behavioral Therapy (CBT) and gut-directed hypnotherapy facilitate dramatic improvements in gastrointestinal symptoms as well as quality of life scores among individuals with a DGBI. Thirty years of research, including randomized controlled trials, have demonstrated significant advantages with these behavioral health treatments, compared to usual medical care, education, antispasmodic and neuromodulator medications, as well as talk therapy (Palsson et al., 2020; Whorwell et al., 1984; Vlieger et al., 2007). Specifically, these treatments have the potential to facilitate an impressive 80% positive response rate for individuals with IBS (Palsson, 2006).
Perhaps even more powerful than the initial positive effects of gut-directed CBT and hypnotherapy treatments is the fact that symptom reduction continues after treatment completion and is maintained over time for many of the participants. In a 1-year follow up on the successful reduction of distress in children with IBS and functional abdominal pain (FAP), 85% of hypnotherapy participants were in remission (Vlieger et al., 2007). In another study reviewing outcomes at almost five years after participation, 68% of patients completing gut-directed hypnotherapy were still in remission, compared to only 20% of those who participated in conventional psychotherapy (Vlieger et al., 2012).
Although studies have thus far predominantly focused on evaluating efficacy with IBS, FAP, and functional nausea, there is some evidence regarding the success of these treatments with other DGBI conditions as well (Calvert et al., 2002; Keefer et al., 2022; Palsson, 2015). This research contributes to a growing interdisciplinary awareness that psychological treatments play a pivotal role in the treatment of individuals with gut-brain conditions (Montero & Jones, 2020). In fact, the American College of Gastroenterology (ACG) has published IBS treatment guidelines recommending referrals for these psychotherapies as part of a comprehensive treatment approach (Lacy et al., 2021).
Considering Intersectional Identities: DGBIs in Sexual and Gender Minorities
Considering the significant, pervasive impact of discrimination and marginalization on the physical and mental health of sexual and gender minorities (SGMs), it is likely that there are increased rates of DGBIs within this population. However, there is a paucity of research in this area. SGMs experience twice the risk of emotional, physical, and sexual trauma, which activates an increased stress response and hypervigilance in the body. Broadly, there also are higher rates of sexually transmitted infections (STI), substance use, mental health conditions, obesity and eating disorders, cancers (breast, cervical, and anorectal), and cardiovascular disease in SGM communities (Zia et al., 2022), several of which are common comorbidities with DGBIs. Consequently, these risk factors may put SGMs at greater risk for DGBIs, but additional research is needed to understand the unique experiences and needs of this population.
Changing the Patient Experience
Ensuring any patient experiencing DGBI distress is aware of effective treatments is essential to them understanding their options and obtaining relief. For many patients with DGBIs, they have been suffering with symptoms for many months or years. It is common for individuals to withdraw from school, work, and social activities. Due to the pain and life interruption, they often feel hopeless and desperate for relief and begin to look at any options that “might” offer relief. Unfortunately, there is a plethora of misinformation and non-licensed service providers that are marketing their services to individuals with IBS and other DGBIs. Additionally, even today some gastrointestinal practices are not aware of gut-brain therapies or are aware and not able to find a qualified provider in their area. As a result of each of these factors, patients have commonly experienced multiple invasive procedures and several unsuccessful treatments. Yet, only a small subset of patients are being connected to a gastro psychologist.
Each clinical health psychologist that is equipped with the knowledge that gut-brain therapies work can make a choice to help empower patients and their community by passing along that information. It will take a larger community effort to ensure that clients, family members, and colleagues know these treatments exist and that there are available qualified professionals. Although a minority of psychologists will decide to invest in cultivating a specialty in gastro psychology, every psychologist can help change the messaging to our clients: there are effective treatments for gut-brain conditions. One of the first steps each clinician can take is to incorporate questions about bowel habit satisfaction and stomach distress into standard intake questions. When a patient endorses distress, questions on the IBS Symptom Severity Scale or gut-related PROMIS scales may serve as inspiration for follow-up questions to help ascertain if a referral to a gastroenterologist and gastro psychologist may be helpful.
Providing psychoeducation, whether offered in a general health psychology setting or in the context of gut-brain therapies, is an essential first step to patients moving towards relief. It is important for patients to understand the neuropsychological connection between their brain, body, and gut, especially as it pertains to hypervigilance and visceral hypersensitivity, and how they can influence their bodies in helpful ways. Providing this education in an empathic and validating way often initiates patient relief and is crucial to reducing the chance that the patient hears the stigmatizing message of “it’s in your head.” Patients must know that providers understand their pain is exceptionally real. They also need the skills to respond to sensations and situations in helpful ways. Ideally, some of these messages are introduced by a primary provider and then continued and expanded upon when they are connected to a gut-brain therapist. When the patient uses gut-directed CBT and clinical hypnosis treatments to create adaptive experiences in their body and mind they start the journey of developing hope and empowerment as well as reengaging in their life.
If you’re interested in learning more about resources for yourself or your clients, consider the following resources:
References
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Ferreira, B. A. G. G. (2023). Eating disorders and gastrointestinal diseases: Relationship, coexistence and state of the art. Retrieved from https://repositorio-aberto.up.pt/bitstream/10216/151297/2/635314.pdf
Jagielski, C. H., & Chang, L. (2021). Gut-brain axis (GBA) and irritable bowel syndrome (IBS). International Foundation for Gastrointestinal Disorders, 133.
Jagielski, C. H., Chey, W. D., & Riehl, M. E. (2021). Influence of trauma on clinical outcomes, quality of life and healthcare resource utilization following psychogastroenterology intervention. Journal of Psychosomatic Research, 146, 11048. https://doi.org/10.1016/j.jpsychores.2021
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