IBS and Anxiety – that “gut feeling” – a holistic approach

People sometimes say that they have a “gut feeling” about something. Once this was just a common phrase, but it has now become a popular research focus, especially how altered brain chemistry from behaviour or mood can alter the gut microbiota. The vicious cycle questioning which came first – did anxiety cause irritable bowel syndrome (IBS), did psychological factors cause physical factors, or vice versa. I have come across so many patients who suffer from both conditions and in practice, I have developed more integrated recommendations to help in their management. Emerging evidence has recently demonstrated that there may be a link between IBS with mental health, including anxiety. This article aims to help dietitians in providing holistic management options for both conditions.

Abdominal pain, discomfort, changes in bowel habits (mostly associated with defecation), bloating, diarrhoea, constipation (or a mix of both) are all too common for patients with IBS. This is especially as it can be a chronic, relapsing and often lifelong disorder.¹ The British Society of Gastroenterology (BSG) guideline in 2007, was reviewed and updated in April 2021 to reflect the advances in the diagnosis and management of IBS. Irritable bowel syndrome is now described as a disorder in the brain-gut interaction, rather than a functional gastrointestinal disorder.²

This correlates with the rise in mental health disorders, including anxiety and behavioural disturbances from perceived fear.³ Anxiety involves multiple systems within the body and can involve biochemical changes leading to physical changes, such as sweating, increased heart rate, deep breathing and in some cases, gastrointestinal symptoms. There are also multiple causes, giving rise to distinct types of anxiety disorders:

• Generalised anxiety disorder
• Social anxiety disorder
• Post-traumatic stress disorder
• Panic disorder
• Obsessive-compulsive disorder
• Body dysmorphic disorder.³

Studies have found that people with IBS are three times more likely to suffer from a mental health condition, such as anxiety.⁴ Individuals who suffer from both IBS and anxiety report more gastrointestinal symptoms and a reduced quality of life. This could impact on sleep, relationships, or lifestyle choices. Although more research is needed in this specific area, the deliberating IBS and anxiety combination has been exacerbated since the COVID-19 pandemic.⁵

There has been no association between anxiety and IBS subtypes, increasing the range of sufferers.⁶ I have found that most patients with IBS can openly recognise they have some degree of psychological influence which may be associated with their physical symptoms. From experience, this ranges diversely from a recent house move increasing short term stress, to studying a degree at university, or on the other end, a diagnosed mental health condition, such as anxiety. All of these can impact on the brain-gut axis in many different ways

Microbial factors have now been shown to impact on the development of IBS symptoms, altering the gut-brain axis.⁷ This is the bidirectional communication between the enteric nervous system and the central nervous system, and involves such pathways, including endocrine, immune, neural, and metabolic.⁸ Any dysregulation to the brain-gut microbiome can lead to dysbiosis (altered intestinal microbiota).8 The powerful influence of your brain can influence your gut, and vice versa.

Management:
It can be a challenge as a dietitian, trying to help a patient manage both IBS and anxiety. It is encouraged to consider non-dietary management too, to promote a more integrated approach to the management of IBS, which may also alter the brain chemistry and positively impact on anxiety symptoms too. Examples can include:

• Regular exercise can increase bowel movements and can be an effective method to reducing symptoms of IBS, particularly those with constipation.⁹
• Medications, such as loperamide can help manage diarrhoea, but this may not help with other symptoms.2 Antispasmodics may also be considered for pain and spasms. Prescribing professionals must be cautious as all medications may lead to unwanted side effects, which may or may not mirror IBS symptoms.² Whilst medications can help, they might also mask the gastrointestinal symptoms, rather than resolving them.
• Psychological therapies such as cognitive behavioural therapy and gut directed hypnotherapy may help, and these can be considered if a year of drug treatments have not been successful.²
• Laughter yoga can be more effective than some anti-anxiety medications.¹⁰ Evidence supports the more yoga practised; the more likely a patient will see improvements in their mental health symptoms.¹¹
• Mindfulness groups, such as meditation can help to increase reported quality of life and symptoms associated with IBS including abdominal pain.¹²
• Acupuncture has been found to help relieve some IBS symptoms, particularly in association with pain and pain management. ^{13, 14}

Most of these non-dietary approaches do not have consistent, strong evidence, but can contribute to a positive lifestyle change (and they do sound appealing!).

In addition to non-dietary management, common diet therapy should be considered:

• First line dietary advice can be provided, and this should be given on an individual basis, related to their diet as a whole and their symptoms. Dietary focuses can include caffeine consumption, alcohol intake, fat intake, and spices.^2,15
• It is also worth considering social aspects of eating, ensuring patients are taking steps to aid good digestion, including sitting upright when eating and not eating too late at night.
• Soluble fibre can be recommended, to help achieve the 30g/day target, but consider avoidance of insoluble fibre at times. It is advisable to build up soluble fibre intake slowly, starting at 3-4g/day initially. This will help to avoid additional bloating associated with fibre increases.²
• The low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet has been shown to be the most effective dietary treatment.¹⁵ It must be recommended and discussed by a FODMAP trained dietitian, in addition to ensuring reintroduction is followed correctly to avoid unnecessary restrictions and to the patient’s tolerance.^2,15
• Peppermint oil can help manage symptoms, but a common side effect can be acid reflux.²
• It must be at least considered that any dietary recommendations, which involve restricting or eliminating foods can alter the gut microbiota negatively. For example, following a low fibre diet may reduce the diversity of the gut microbiota, as it is reducing the number of potential prebiotics consumed.
• Therefore, dietitians can consider recommending prebiotics or probiotics to increase the diversity in the gut microbiota again.^2,15 Encourage plant-based products, to increase variety and plant diversity. Provide probiotic options for patients to choose from.
• There is no convincing evidence for elimination diets based on IgG antibodies, nor any evidence for gluten free diets in IBS (unless otherwise indicated with another diagnosis, such as Coeliac Disease).²

Anxiety and IBS are both complex conditions and involve numerous psychological and physical interactions. There has been little research on individuals diagnosed with both conditions, and this is an area to focus on going forward.¹⁶ Dietary management and non-dietary approaches can help to compliment the management of IBS and anxiety, providing a more inclusive and patient centred approach. A combination of therapies may help to reduce the cost of pharmacological options and promote more exercise and wellbeing options out there for all to enjoy. Encourage self-management where indicated, in addition to diet therapy!

Author Bio:

Hannah Pritchard is a UK registered Dietitian, specialising in conditions of the gastrointestinal system. She is particularly interested in IBS, Crohn's disease, Ulcerative colitis and Coeliac disease. Working in the NHS, voluntary and private sectors has enabled her to develop a range of experiences, working with a mixture of people to improve their gut health and achieve their nutrition goals.