The Health Psychologist

Society for Health Psychology

Evidence and Application of Health Psychology Interventions to Improve Management of Irritable Bowel Syndrome

2023 Spring, Research highlights, The Health Psychologist

Brooke Palmer, PhD
Assistant Professor, Division of Geriatrics, Primary Care, and Palliative Care, Department of Medicine, University of Minnesota Medical School

Megan Petrik, PhD, ABPP
Assistant Professor, Division of Geriatrics, Primary Care, and Palliative Care, Department of Medicine, University of Minnesota Medical School


Psychogastroenterology is an exciting and growing field of health psychology that capitalizes on the strengths of psychologists as researchers, clinicians, and educators and applies our skills to support patients living with gastrointestinal (GI) disorders to promote well-being and symptom management (Keefer et al., 2018). Psychogastroenterologists work with patients to cope with the emotional impacts of living with a GI condition, including the impact on quality of life, any comorbid depression and anxiety, or the common experiences of stigma patients report related to their symptoms. They may also work to intervene upon the brain-gut axis to promote GI symptom relief. The brain-gut axis refers to the bidirectional communication that occurs between the brain (central nervous system) and the gut (enteric nervous system), which is modulated by stress. The central nervous system sends messages to the gut to coordinate digestion and responds to one’s thoughts and emotions, and the gut provides information to the brain’s cognitive and emotional regions in the form of hormones and neurotransmitters. Multiple factors play a role in the etiology of disorders of gut-brain interaction (DGBIs). These include infection, inflammation, dysbiosis, prolonged stressors, or trauma. There are over 20 conditions that arise from disruptions in the brain-gut axis and include such diagnoses as irritable bowel syndrome (IBS), functional dyspepsia, and functional abdominal pain (Drossman et al., 2016).

IBS is the most common DGBI and is characterized by recurrent abdominal pain, changes in stool frequency and/or form and occurring for at least 6 months (Drossman et al., 2016). Bloating and abdominal distention are also common. In individuals with IBS, there can be dysfunction in various parts of the gut-brain axis that contribute to reported symptoms. The neurons which control motility and sensation may be dysregulated and lead to problematic motor function (e.g., constipation or diarrhea) and/or pain. Alterations in sensation may include visceral hypersensitivity (normal physiological digestive processes are perceived as uncomfortable or painful) or central sensitization (heightened response of pain-related neurons to non-painful stimuli). Patients with visceral hypersensitivity may report high levels of pain in response to normal digestive responses or have lower pain tolerance than healthy controls. Simrén et al. (2018) analyzed data from five cohorts of patients with DGBIs (N = 1144) and found that increasing visceral hypersensitivity was significantly associated with patient report of GI symptom severity, independent of anxiety, depression, or somatization symptoms. Results indicate that visceral hypersensitivity contributes to GI symptom generation in IBS and is a target for intervention.

There are multiple cognitive and behavioral factors common in patients with IBS, which include visceral anxiety, catastrophic thought patterns, inflexible coping approaches, and attentional bias (Kinsinger, 2017). Visceral anxiety refers to patterns of fear and worry about not only GI sensations but also places and situations where they may be more likely to occur (i.e., eating). Patients tend to be hypervigilant of their sensations. Individuals with IBS that have high levels of visceral anxiety tend to perceive normal GI sensations as threatening. This can lead to catastrophic thought patterns and attentional bias. These may be familiar targets to clinicians working within a cognitive behavioral therapy (CBT) framework. In patients with IBS, these cognitive processes are applied towards GI symptoms and reinforce disturbances in the gut-brain axis and maintain symptoms.

Psychogastroenterologists are uniquely poised to support these patients by implementing brain-gut behavior therapies when indicated. Behavior therapies are utilized when patients have not responded to or even in conjunction with standard treatment (i.e., medical management, lifestyle modification, dietary changes) or neuromodulator medication and have more severe GI symptoms. Specifically, cognitive behavior therapy (CBT) and gut-directed hypnotherapy are effective interventions for patients with IBS that can reduce not only psychological distress but also a range of IBS symptoms and their interference on one’s functioning.

CBT for IBS involves providing patient psychoeducation about the biopsychosocial etiology of IBS and influence of brain-gut dysregulation on symptoms. Additional strategies include relaxation training and challenging unhelpful thinking and behavior patterns associated with digestive symptoms. Patients are encouraged to acknowledge connections between their thinking about GI symptoms, their behavioral patterns designed to manage or prevent symptoms, and their feelings. Meta-analyses and systematic reviews demonstrate improvement in GI and mental health symptoms compared to control groups, and results remain in the short- and long-term. Of important note in the era of increased access to telehealth and self-guided interventions, CBT via internet and telephone are also superior to routine care (Ford et al., 2019; Black et al., 2020). Mediation analyses have highlighted that changing GI-related cognitions, GI-specific anxiety, and safety behaviors lead to improvement in IBS symptom report and functioning (Windgassen et al., 2019).

Another efficacious and novel intervention for patients with IBS is gut-directed hypnotherapy. Along with CBT, it has the most empirical evidence for efficacy in managing IBS symptoms (Black et al., 2020). This therapy implements verbal cues to induce a mental state of openness to therapeutic suggestions designed to lead to GI symptom changes. Patients are introduced to a deep state of relaxation where they are exposed to suggestions about visceral anxiety, cognitive-affective processes, and central pain amplification (Riehl, 2020). Suggestions are highly personalized both in terms of the GI focus and the imagery used. In their 2019 meta-analysis, Ford et al. (2019) found that five randomized controlled trials (RCTs) demonstrated improvement in IBS symptom severity when compared to control participants, as well as improved quality of life and reduced healthcare utilization (Vasant & Whorwell, 2018). There is evidence that hypnosis leads to GI symptom improvement via normalizing multiple disrupted patterns, such as visceral hypersensitivity and motility. Studies have also demonstrated effects on maladaptive thought patterns as a mechanism of effectiveness (Keefer et al., 2022). While exact mechanisms for change remain unclear, fMRI studies suggest changes in neuroplasticity play a role (Vasant & Whorwell, 2018).

This article highlights how the field of psychogastroenterology has leveraged its strengths in research and clinical skills and set its sights on targeting patients living with chronic digestive symptoms, specifically in the case of IBS. However, IBS is just one of many disorders under the GI umbrella. The future is vast for researchers and clinicians who want to be involved in this burgeoning field. Research is needed to further intervention efforts with various GI patient populations, to identify factors that predict treatment response, and to further elucidate treatment mechanisms. Of note, this area is ripe for those with interprofessional interests. Our colleagues in pharmacy, gastroenterology, and nutrition are ready and waiting for us!


Black, C. J., Thakur, E. R., Houghton, L. A., Quigley, E. M., Moayyedi, P., & Ford, A. C. (2020). Efficacy of psychological therapies for irritable bowel syndrome: Systematic review and network meta-analysis. Gut, 69(8), 1441-1451. doi: 10.1136/gutjnl-2020-321191

Drossman, D. A. (2016). Functional gastrointestinal disorders: History, pathophysiology, clinical features, and Rome IV. Gastroenterology, 150(6), 1262-1279.

Ford, A. C., Lacy, B. E., Harris, L. A., Quigley, E. M., & Moayyedi, P. (2019). Effect of antidepressants and psychological therapies in irritable bowel syndrome: An updated systematic review and meta-analysis. American  Journal of Gastroenterology, 114(1), 21-39. doi: 10.1038/s41395-018-0222-5

Keefer, L., Ballou, S. K., Drossman, D. A., Ringstrom, G., Elsenbruch, S., & Ljótsson, B. (2022). A Rome working team report on brain-gut behavior therapies for disorders of gut-brain interaction. Gastroenterology, 162(1), 300-315. doi: 10.1053/j.gastro.2021.09.015

Keefer, L., Palsson, O. S., & Pandolfino, J. E. (2018). Best practice update: Incorporating psychogastroenterology into management of digestive disorders. Gastroenterology, 154(5), 1249-1257.

Kinsinger, S. W. (2017). Cognitive-behavioral therapy for patients with irritable bowel syndrome: Current insights. Psychology Research and Behavior Management, 10, 231

Riehl, M. E. (2019). Hypnosis approaches to gastrointestinal conditions. In S. R. Knowles, L. Keefer, & A. Mikocka-Walus (Eds.), Psychogastroenterology for Adults  (pp. 216-235). Routledge.

Simrén, M., Törnblom, H., Palsson, O. S., van Tilburg, M. A., Van Oudenhove, L., Tack, J., & Whitehead, W. E. (2018). Visceral hypersensitivity is associated with GI symptom severity in functional GI disorders: Consistent findings from five different patient cohorts. Gut, 67(2), 255-262. doi: 10/1136/gutjnl-2016-312361

Vasant, D. H., & Whorwell, P. J. (2019). Gut‐focused hypnotherapy for functional gastrointestinal disorders: Evidence‐base, practical aspects, and the Manchester protocol. Neurogastroenterology & Motility, 31(8), e13573. doi: 10.1111/nmo.13573

Windgassen, S., Moss‐Morris, R., Chilcot, J., Sibelli, A., Goldsmith, K., & Chalder, T. (2017). The journey between brain and gut: A systematic review of psychological mechanisms of treatment effect in irritable bowel syndrome. British Journal of Health Psychology, 22(4), 701-736. doi: 10.1016/j.jpsychores.2018.11.013