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By Jeffrey Lackner, PsyD

The past 20 years has seen an explosion of research on non-drug treatments for painful medical disorders including irritable bowel syndrome (IBS). Disorders that were once seen as untreatable are now regarded as treatable. Hope has replaced helplessness. One particularly exciting area is the use of a specific behavioral treatment called cognitive behavioral therapy (CBT) to relieve even the most severe pain and bowel problems of IBS.

“The focus of Cognitive Behavioral Therapy is what maintains a problem not what causes a problem.”

Unlike other psychological treatment, CBT focuses on the here and now – how our current thoughts and behaviors impact health. So there is no lying on a coach, “analyzing”, free-associating, or open ended discussion that is part of “talk therapy”. The focus of CBT is what maintains a problem not what causes a problem. The practice of CBT rests on its own set of underlying assumptions. These assumptions are based on experimental research that tells us many of our reactions are learned and form our behavioral skill set. In a nut shell, CBT assumes that:

• Patients have specific skills deficits related to their disease that make them vulnerable to symptom flares. These skills deficits can be behavioral ones as for example difficulty regulating tension in the body that can disrupt brain-gut interactions or maladaptive coping strategies such as excessive avoidance or reliance on safety-behaviors (reassurance seeking from doctor that their abdominal pain doesn’t mean they have cancer). Deficits can also reflect biases in their salience system leading to exaggerated threat appraisals which crank up the volume of the body’s stress response system. These mental traps can disrupt brain-gut interactions and when this happens symptoms flare.
• The same processes that create deficits can be used to remediate them. In other words, just as these skills deficits are learned, they can be unlearned by learning more effective symptom self-management skills.
• By remediating these skills deficits, patients can gain control over GI symptoms and eventually manage, if not control, their symptoms on their own even when medications have not done the trick.

“…there is little evidence that relaxation training alone can be effective in reducing the painful medical disorders that our patients struggle with.”

There is no one regimen of CBT any more than there is one hypertension medication or one physical therapy regimen. Treatments differ with respect to their length and emphasis. Treatment can last anywhere from 4 to 20 sessions, be delivered at home via the internet or in a clinic in an individual or group setting. Some treatments place more emphasis on behavioral (the B of CBT) strategies such as relaxation or social skills training. Others are more cognitive (the C of CBT) in that they emphasize skills for helping patients assess the salience of events more effectively.

At our center, our emphasis has evolved over the years. We used to emphasize relaxation training more than we do now for two reasons. First, there is little evidence that relaxation training alone can be effective in reducing the painful medical disorders that our patients struggle with. We also know that relaxation can actually prevent some patients from gaining control of symptoms when it is used as a way of eliminating anxiety that is best tackled through more resilience-building strategies like “decatastrophizing”. There is a place for relaxation but it probably is best used in moderation a way of taking the edge off tension and building confidence to confront threatening situations. We also have been influenced by research from our colleagues at UCLA and other institutions showing that our patients are vulnerable to specific thinking errors that aggravate symptoms. One trap is a tendency to intense worry. The thought processes of many chronic worriers, involve “catastrophizing” which is a way of thinking that tends to define increasingly worse and worse outcomes to a specific problem. This is characterized by “What if…?” question that worriers perpetually ask about a problem without generating a solution. Roberta worrying about needing to use the bathroom as she gets ready for a first date is an example.

“The thought processes of many chronic worriers, involve “catastrophizing” which is a way of thinking that tends to define increasingly worse and worse outcomes to a specific problem.”

Chronic worriers like Roberta tend to define significantly more catastrophic consequences for a worry topic and report a significant increase in discomfort catastrophizing progresses. In Roberta’s case, worry didn’t just stop at the thought of needing to use the bathroom during the middle of dinner but continued on: What would my date think? What if I cant find the bathroom? What if someone is using it? What If I lose control on the way to the bathroom? This sequence of questions illustrates how Roberta is very skilled at defining problems but less skilled at generating a solution for any of them. This tendency to define events as threat makes it hard to problem solve around a given problem Worse, it likely leads them to reject potential solutions because worry cast a dark shadow on other options seen as not good enough. Worrying also likely interferes with the problem solving process by inflating the severity (or manageability) of a problem. These effects prolong the problem (through catastrophizing), significantly reducing the likelihood of arriving at an acceptable solution, and maintaining anxiety that can fuel symptoms.

“…worrying about low probability events is usually reinforced when the anticipated scary outcome doesn’t happen.”

One of the interesting features of worrying is that it functions as a cognitive avoidance of external threats and is negatively reinforced in two ways. First, worrying about low probability events is usually reinforced when the anticipated scary outcome doesn’t happen (Roberta treats the notion of losing control of her bowels on the way to bathroom as a stone cold fact that has actually never happened!), leading to more unproductive worry. Second because of the nature of worry, it takes a lot of “storage space” in our brain, meaning that worrying provides an escape from threatening images which otherwise trigger uncomfortable physical reactions like increased heartbeat, sweating and other stress reactions. What this means is that actually worriers experiences less physiological arousal, they do so at the expense of preventing themselves from processing emotionally charged material required for their anxiety to decrease. Simply put, the worrier learns to worry to reduce the unpleasant sensations caused by worrying. Worry control skills can help patients gain control over worry so that they learn when worry is constructive and when it is not helpful and a source of symptom aggravating stress. Patients learn to test out exaggerated predictions about possible future threats (“what if…?) based on information available to them at present. Evidence-based logic can be facilitated by the patient asking themselves the following:

• What evidence do I have for this thought?
• Are my thoughts based on hard facts (vs feeling)?
• Is there another alternative explanation for looking at things?
• What would I recommend to my best friend if s/he were in the same situation?

“The goal of flexible problem solving is to help patients develop a more flexible regimen of coping skills that help them manage a broad range of stressors.”

Another science-based technique we have developed at our center is called flexible problem solving. The goal of this strategy is to help patients develop a more flexible regimen of coping skills that help them manage a broad range of stressors. Problems that are controllable require solution-based coping responses that include defining a problem, brainstorming solutions, implementing one, and evaluating its effectiveness. Not all problems can be fixed, however, and those that are uncontrollable call for what are called emotion focused coping response. Emotion-focused coping responses are aimed at minimizing the emotional unpleasantness a stressor triggers and include decatastrophizing techniques like asking “so what is the worst thing that would happen if my worries came true?”, relaxation, obtaining support, and acceptance. These skills don’t fix a problem but they can contain the emotional fallout that helps patients manage the day to day burden of their symptoms.

“The efficacy of CBT is unmatched by dietary and pharmacological alternatives.”

In research that we have conducted over the past 20 years, the version of CBT that teaches these skills is the only psychological treatment for IBS that has met “strong evidence” criteria for an empirically validated treatment. Its overall efficacy profile (i.e. IBS symptom improvement, onset of action, and long-term durability) is unmatched by dietary and pharmacological alternatives. Other groups have developed effective treatments of CBT delivered through the web with and without therapist support.

References

• • Lackner JM, Jaccard J, Keefer L, et al.: Improvement in Gastrointestinal Symptoms After Cognitive Behavior Therapy for Refractory Irritable Bowel Syndrome. Gastroenterology. 2018, 155:47-57.
  • Society of Clinical Psychology (Division 12): Empirically-Supported Psychological Treatments Retrieved December 29, 2020, 2020
  • Lackner JM: Skills over pills? A clinical gastroenterologist’s primer in cognitive behavioral therapy for irritable bowel syndrome. Expert Rev Gastroenterol Hepatol. 2020, 14:601-618.

Lackner JM, Jaccard J, Radziwon CD, et al.: Durability and Decay of Treatment Benefit of Cognitive Behavioral Therapy for Irritable Bowel Syndrome: 12-Month Follow-Up. American Journal of Gastroenterology. 2019, 114:330-338.

Jeffrey Lackner, PsyD is Professor of Medicine at the Jacobs School of Medicine at the University of Buffalo where he is the Chief of the Division of Behavioral Medicine. He is a pioneer in the development and testing of Cognitive Behavioral Therapy (CBT) for disorders such as Irritable Bowel Syndrome (IBS).