Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS. Irritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS. Irritable bowel syndrome (IBS) is a symptom-based condition in which affected patients experience recurrent bouts of abdominal pain and altered bowel habits.1Mearin F. Lacy B. Chang L. et al.Rome IV: the functional bowel disorders.Gastroenterology. 2016; 150: 1393-1407Abstract Full Text Full Text PDF Scopus (0) Google Scholar IBS is important not only because it is prevalent, affecting 10%–20% of the general population, but also because of its significant impact on quality of life and overall cost to the health care system and society at large.2Chey W.D. Eswaran S. Kurlander J. Management of irritable bowel syndrome.JAMA. 2015; 313: 949-958Crossref PubMed Scopus (0) Google Scholar Like the clinical phenotype, the pathogenesis of IBS is diverse. During the course of the last 60 years, a wide range of factors have been suggested to contribute to the development of IBS, including abnormalities in motility, visceral sensation, brain–gut interactions, gut microbiota, gut permeability, immune activation, genetics, and exposure or reactions to psychosocial stressors.3Talley N.J. What causes functional gastrointestinal disorders? A proposed disease model.Am J Gastroenterol. 2020; 115: 41-48Crossref PubMed Scopus (12) Google Scholar Traditionally, treatment has focused on the use of over-the-counter and prescription medications to improve 1 or more IBS symptoms. Although a number of medications have proven more effective than placebo, most lead to clinical benefits in fewer than one-half of treated patients and yield therapeutic gains over placebo of between 7% and 14%.4Ford A.C. Moayyedi P. Chey W.D. et al.American College of Gastroenterology monograph on the management of IBS.Am J Gastroenterol. 2018; 113: 1-18Crossref PubMed Scopus (71) Google Scholar Furthermore, nearly all medications only work when taken, necessitating long-term therapy. Medication-related adverse events and costs can also create barriers to the use of medications for patients and providers. In aggregate, patients have increasingly challenged the medical community to think more creatively about nonmedical solutions to address their IBS symptoms.5Halpert A. Dalton C.B. Palsson O. et al.What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ).Am J Gastroenterol. 2007; 102: 1972-1982Crossref PubMed Scopus (137) Google Scholar The last 20 years has seen an explosion in our knowledge surrounding the role of environmental variables that might be manipulated to the benefit of patients with IBS.6Barbara G. Feinle-Bisset C. Ghoshal U.C. et al.The intestinal microenvironment and functional gastrointestinal disorders.Gastroenterology. 2016; 150: 1305-1318Abstract Full Text Full Text PDF Google Scholar Chief among this research is the growing recognition of food and cognitive/emotional factors as important triggers for symptoms in patients with IBS.7Liu J. Chey W.D. Haller E. et al.Low FODMAP diet for irritable bowel syndrome: what we know and what we have yet to learn.Ann Rev Med. 2020; 71: 303-314Crossref PubMed Scopus (1) Google Scholar,8Roohafza H. Bidaki E.Z. Hasanzadeh-Keshteli A. et al.Anxiety, depression and distress among irritable bowel syndrome and their subtypes: an epidemiological population based study.Adv Biomed Res. 2016; 5: 183Crossref PubMed Google Scholar The fact that food and stress are important to the illness experience of patients with IBS is by no means a new concept. However, the translation of the science to evidence-based management options for patients with IBS has largely occurred since the turn of this century. The goal of this article was to review the evidence that supports the use of behavioral therapies and a diet low in poorly absorbed, fermentable carbohydrates in IBS and to provide a rationale for the growing adoption of integrated care models for patients with IBS. The main goals of treating patients with IBS are to improve overall symptoms, sense of well-being, and quality of life. Frustratingly, there is often discord between gastrointestinal (GI) symptom alleviation and improvements in quality of life. For instance, satisfaction with bowel movements is often not associated with objective change in the appearance or water content of feces.9Halmos E.P. Biesiekierski J.R. Newnham E.D. et al.Inaccuracy of patient-reported descriptions of and satisfaction with bowel actions in irritable bowel syndrome.Neurogastroenterol Motil. 2018; 30Crossref PubMed Scopus (4) Google Scholar Likewise, reducing stool frequency with loperamide in patients with IBS with diarrhea (IBS-D) has a poor record of improving overall well-being.10Cangemi D.J. Lacy B.E. Management of irritable bowel syndrome with diarrhea: a review of nonpharmacological and pharmacological interventions.Therap Adv Gastroenterol. 2019; 12: 1-19Crossref Scopus (3) Google Scholar Perhaps related is that patients with IBS often endorse symptoms extending beyond abdominal pain and altered bowel habits. For example, a recent population-based study of more than 71,000 US citizens found that 10%–50% of people with lower GI symptoms also reported upper GI symptoms, such as heartburn, dysphagia, or nausea.11Almario C. Chey W.D. Spiegel B.M.R. Burden of gastrointestinal symptoms in the United States: results of a nationally representative survey of over 71,000 Americans.Am J Gastroenterol. 2018; 113: 1701-1710Crossref PubMed Scopus (17) Google Scholar Similarly, a substantial proportion of patients with IBS endorse non-GI symptoms, such as fatigue, insomnia, depression, and anxiety,12JungyounHan C. SuYang G. Fatigue in irritable bowel syndrome: a systematic review and meta-analysis of pooled frequency and severity of fatigue.Asian Nurs Res. 2016; 10: 1-10Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 13Tu Q. Heitkemper M.M. Jarrett M.E. et al.Sleep disturbances in irritable bowel syndrome: a systematic review.Neurogastroenterol Motil. 2017; 29Crossref Scopus (16) Google Scholar, 14Lee C. Doo E. Choi J.M. et al.The increased level of depression and anxiety in irritable bowel syndrome patients compared with healthy controls: systematic review and meta-analysis.J Neurogastroenterol Motil. 2017; 23: 349-362Crossref PubMed Scopus (44) Google Scholar all of which are known to negatively impact quality of life. It follows that behavioral therapy within a gastroenterology clinic for patients with functional GI disorders led to considerable improvement and satisfaction in patients compared with those not receiving it, even though gastrointestinal symptom severity was unchanged.15Kruimel J. Leue C. Winkens B. et al.Integrated medical-psychiatric outpatient care in functional gastrointestinal disorders improves outcome: a pilot study.Eur J Gastroenterol Hepatol. 2015; 27: 721-727Crossref PubMed Scopus (15) Google Scholar In several other chronic conditions, such as diabetes or arthritis, collaborative or integrated management, defined as care that strengthens and supports self-care while assuring that effective medical, preventive, and health maintenance interventions take place, is associated with improved outcomes.16Von Korff M. Gruman J. Schaefer J. et al.Collaborative management of chronic illness.Ann Intern Med. 1997; 127: 1097-1102Crossref PubMed Google Scholar Likewise, IBS is a chronic condition of diverse pathogenesis. That said, with few exceptions, the current medical model of gastroenterologist-only specialist care fails to deliver such collaborative management. Indeed, in the few outcome evaluations of the traditional Western management model, patient quality of life was unchanged17Canavan C. West J. Card T. Change in quality of life for patients with irritable bowel syndrome following referral to a gastroenterologist: a cohort study.PLoS One. 2015; 10e0139389Crossref PubMed Scopus (15) Google Scholar,18Basnayake C. Kamm M.A. Salzberg M. et al.Outcome of hospital outpatient treatment of functional gastrointestinal disorders.Intern Med J. 2018; 49: 225-231Crossref Scopus (4) Google Scholar and rates of patient dissatisfaction were high.19Linedale E.C. Shahzad M.A. Kellie A.R. et al.Referrals to a tertiary hospital: a window into clinical management issues in functional gastrointestinal disorders.JGH Open. 2017; 1: 84-91Crossref PubMed Scopus (4) Google Scholar Limitations of the current Western medical model include lack of time for providers to take a more holistic approach to care; a focus on pharmacologic management; inadequate training; and lack of access to specific dietary, psychological, and other management strategies. It is logical that involvement of other health professionals with greater time available, with skills in other therapeutic techniques, and with training in behavioral techniques to improve self-care will improve outcomes for patients with IBS. Furthermore, the ability to share the burden of management can also reduce burnout among physician providers. Integrated care models, in which multidisciplinary teams work collaboratively, have been developed by an ever-increasing number of GI practices to more effectively manage their patients with IBS. However, to date, credible evidence of improved outcomes with such models is scant.20Basnayake C. Kamm M.A. Salzberg M.R. et al.Delivery of care for functional gastrointestinal disorders: a systematic review.J Gastroenterol Hepatol. 2019; 35: 204-210Crossref PubMed Scopus (2) Google Scholar,21Linedale E.C. Mikocka-Walus A. Gibson P.R. et al.The potential of integrated nurse-led models to improve care for people with functional gastrointestinal disorders: a systematic review.Gastroenterol Nurs. 2020; 43: 53-64Crossref PubMed Scopus (0) Google Scholar Limited data from studies that evaluated nurse or dietitian-led clinics with strict entry criteria have reported high rates of satisfaction for patients with functional GI symptoms.21Linedale E.C. Mikocka-Walus A. Gibson P.R. et al.The potential of integrated nurse-led models to improve care for people with functional gastrointestinal disorders: a systematic review.Gastroenterol Nurs. 2020; 43: 53-64Crossref PubMed Scopus (0) Google Scholar, 22Ryan D. Pelly F. Purcell E. The activities of a dietitian-led gastroenterology clinic using extended scope of practice.BMC Health Serv Res. 2016; 16: 604Crossref PubMed Scopus (8) Google Scholar, 23Mutsekwa R.N. Larkins V. Canavan R. et al.A dietitian-first gastroenterology clinic results in improved symptoms and quality of life in patients referred to a tertiary gastroenterology service.Clin Nutr ESPEN. 2019; 33: 188-194Abstract Full Text Full Text PDF PubMed Google Scholar Nurse-led clinics for patients with chronic constipation or fecal incontinence achieved excellent outcomes, but these programs involved institution of specific treatment algorithms.24Iqbal F. Askari A. Adaba F. et al.Factors associated with efficacy of nurse-led bowel training of patients with chronic constipation.Clin Gastroenterol Hepatol. 2015; 13: 1785-1792Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar,25Duelund-Jakobsen J. Haas S. Buntzen S. et al.Nurse-led clinics can manage faecal incontinence effectively: results from a tertiary referral centre.Colorectal Dis. 2015; 17: 710-715Crossref PubMed Scopus (14) Google Scholar When psychological services are integrated into the clinic, benefits have been described in 2 prospective cohorts.15Kruimel J. Leue C. Winkens B. et al.Integrated medical-psychiatric outpatient care in functional gastrointestinal disorders improves outcome: a pilot study.Eur J Gastroenterol Hepatol. 2015; 27: 721-727Crossref PubMed Scopus (15) Google Scholar,26Kinsinger S.W. Ballou S. Keefer L. Snapshot of an integrated psychosocial gastroenterology service.World J Gastroenterol. 2015; 21: 1893-1899Crossref PubMed Google Scholar Patients who persisted with psychological interventions had fewer subsequent medical procedures in 1 study, and improvements in psychological status and quality of life without alteration in severity of abdominal symptoms was observed in another. The use of a 3-hour educational program delivered by an allied health team, in addition to standard gastroenterologist-delivered care, was associated with improved alleviation of symptoms.27Saito Y.A. Prather C.M. Van Dyke C.T. et al.Effects of multidisciplinary education on outcomes in patients with irritable bowel syndrome.Clin Gastroenterol Hepatol. 2004; 2: 576-584Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Four different approaches have been evaluated in Australia. First, a pilot study in family physicians, which utilized an algorithmic approach that avoided specialist involvement and provided pathways for multidisciplinary management, was well accepted and improved outcomes.28Linedale E.C. Mikocka-Walus A. Vincent A.D. et al.Performance of an algorithm-based approach to the diagnosis and management of functional gastrointestinal disorders: a pilot trial.Neurogastroenterol Motil. 2018; 30e13243Crossref Scopus (3) Google Scholar Second, a structured multidisciplinary program showed benefit over standard care.29Bray N. Koloski N. Jones M. et al.12-week multidisciplinary integrated treatment approach is superior to standard care for symptom reduction in patients with functional gastrointestinal disorders: a case–control study.J Gastroenterol Hepatol. 2019; 34: 168Google Scholar Third, a nurse-led multidisciplinary individualized program showed improved quality of life and symptoms, as well as reduced investigation and costs in a case–control study.30McNamara L. Wood J. Moore J. et al.A nursing and allied health-led functional gastrointestinal disorders clinic is well received by patients, highly efficient, cost-effective, and reduces the need for medical intervention.J Gastroenterol Hepatol. 2019; 34: 169PubMed Google Scholar Perhaps the most persuasive data to date came from an unblinded, randomized study of 188 patients with IBS in which a gastroenterologist-led integrated, multidisciplinary care model showed improved clinical outcomes, quality of life, psychological health, and cost-effectiveness compared with standard care.31Basnayake C. Kamm M.A. Stanley A. et al.Optimal delivery of care for functional gastrointestinal disorders: randomized controlled trial of standard gastroenterologist-only care versus multidisciplinary care (MANTRA study).J Gastroenterol Hepatol. 2019; 34: 182Google Scholar It is notable that gastroenterologists in the standard care arm were permitted to order consultations with a dietitian or behavioral therapist outside of their hospital, and gastroenterologists working in the integrated care group had immediate access to on-site services from a dietitian or behavioral therapist. Patients in the integrated care group were significantly more likely to be seen by a dietitian or behavioral therapist. For the primary outcome, 84% of patients with IBS in the integrated care arm reported a significant improvement in global IBS symptoms vs 57% in the standard care arm (P < .001). This study’s results suggest that a team-based, collaborative care model offers measurable benefits over simply having access to a dietitian or behavioral therapist. This might be because open communication between team members enables shared identification of, and decision-making about, important clinical issues. For example, hypervigilance and disordered eating behaviors are ideally addressed jointly by all members of the collaborative team. In other words, the whole of the integrated team is greater than the sum of its parts. In the following sections, we will critically review the strengths and weaknesses of behavioral- and diet-based therapies for IBS. Brief behavioral therapies, offered in conjunction with medical therapies, appear to be effective for reducing abdominal pain and improving satisfaction with bowel habits in a subset of patients for whom stress, hyperarousal, anxiety, fear, or maladaptive thoughts drive symptoms. GI behavioral therapies were adapted from highly effective behavioral therapies used to treat anxiety and chronic pain to more specifically address dysregulation of the brain–gut axis (Table 1). Adaptation focuses on 2 primary pathways through which behavior modification, and hence, GI symptom reduction, could occur. First, techniques with potential to modify dysregulated (ascending) gut-to-brain pathways leverage established behavioral techniques focused on re-interpreting benign sensations in the body, in this case from the gut, that could trigger maladaptive cognitive or affective processes in the brain. Second, techniques that potentially modify dysregulated (descending) brain-to-gut pathways, in which GI symptoms occurred in response to cognitive and affective triggers arising from the fear of symptoms; lack of acceptance of disease; or from stressors in the external environment, can also offer benefit to some patients with IBS. We will describe a practical approach to implementation of the behavioral techniques most commonly employed in brain–gut psychotherapies, although efficacy data on specific techniques are limited (Figure 1).Table 1Behavioral Therapies for Irritable Bowel SyndromeClass of behavior therapy for IBSPrimary techniquesDurationDelivery mechanismsLevel of evidenceaLevel of evidence for these therapies is based on use in conjunction with medical therapies, and is based primarily on patients with moderate to severe symptoms. However, given their safety and complementary nature, these therapies can be recommended for any patient at any point in treatment.GI CBTbDenotes class of behavior therapy that could be called brain–gut psychotherapy.Modification of arousal (relaxation training) Cognitive reframing, including catastrophizing Behavioral/emotional/interoceptive exposure4–8 sessions over 12–16 wk, might include homeworkIn person, group, online, self-help bookLevel 1, moderate57Ford A.C. Lacy B.E. Harris L.A. et al.Effect of antidepressants and psychological therapies in irritable bowel syndrome: an updated systematic review and meta-analysis.Am J Gastroenterol. 2019; 114: 21-39Crossref PubMed Scopus (48) Google Scholar,58Laird K.T. Tanner-Smith E.E. Russell A.C. et al.Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: a systematic review and meta-analysis.Clin Psychol Rev. 2017; 51: 142-152Crossref PubMed Scopus (55) Google Scholar,131Radu M. Moldovan R. Pintea S. et al.Predictors of outcome in cognitive and behavioural interventions for irritable bowel syndrome. A meta-analysis.J Gastrointestin Liver Dis. 2018; 27: 257-263Crossref PubMed Scopus (3) Google Scholar,132Li L. Xiong L. Zhang S. et al.Cognitive-behavioral therapy for irritable bowel syndrome: a meta-analysis.J Psychosom Res. 2014; 77: 1-12Crossref PubMed Google ScholarGut-directed hypnotherapybDenotes class of behavior therapy that could be called brain–gut psychotherapy.Modification of arousal Subconscious suggestions related to improved gut–brain communication and symptom perception, particularly pain7–12 sessions over 12–16 wk, 20 min/d home practiceIn person, group, onlineLevel 1, moderate57Ford A.C. Lacy B.E. Harris L.A. et al.Effect of antidepressants and psychological therapies in irritable bowel syndrome: an updated systematic review and meta-analysis.Am J Gastroenterol. 2019; 114: 21-39Crossref PubMed Scopus (48) Google Scholar,58Laird K.T. Tanner-Smith E.E. Russell A.C. et al.Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: a systematic review and meta-analysis.Clin Psychol Rev. 2017; 51: 142-152Crossref PubMed Scopus (55) Google Scholar,133Lee H.H. Choi Y.Y. Choi M.G. The efficacy of hypnotherapy in the treatment of irritable bowel syndrome: a systematic review and meta-analysis.J Neurogastroenterol Motil. 2014; 20: 152-162Crossref PubMed Scopus (0) Google Scholar,134Schaefert R. Klose P. Moser G. et al.Efficacy, tolerability, and safety of hypnosis in adult irritable bowel syndrome: systematic review and meta-analysis.Psychosom Med. 2014; 76: 389-398Crossref PubMed Scopus (0) Google ScholarMindfulness-based stress reductionModification of arousal Stress reduction8 wk, 1 weekend retreat, 45 min practice/dGroupLevel 2, moderate40Gaylord S.A. Palsson O.S. Garland E.L. et al.Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized controlled trial.Am J Gastroenterol. 2011; 106: 1678-1688Crossref PubMed Scopus (163) Google Scholar,135Ghandi F. Sadeghi A. Bakhtyari M. et al.Comparing the efficacy of mindfulness-based stress reduction therapy with emotion regulation treatment on quality of life and symptoms of irritable bowel syndrome.Iran J Psychiatry. 2018; 13: 175-183PubMed Google Scholar, 136Harding K. Simpson T. Kearney D.J. Reduced symptoms of post-traumatic stress disorder and irritable bowel syndrome following mindfulness-based stress reduction among veterans.J Altern Complement Med. 2018; 24: 1159-1165Crossref PubMed Scopus (2) Google Scholar, 137Zernicke K.A. Campbell T.S. Blustein P.K. et al.Mindfulness-based stress reduction for the treatment of irritable bowel syndrome symptoms: a randomized wait-list controlled trial.Int J Behav Med. 2013; 20: 385-396Crossref PubMed Scopus (87) Google ScholarPsychodynamic interpersonal psychotherapyInterpersonal difficulties, trauma, somatization16–20 wkIndividualLevel 2,55Hyphantis T. Guthrie E. Tomenson B. Creed F. Psychodynamic interpersonal therapy and improvement in interpersonal difficulties in people with severe irritable bowel syndrome.Pain. 2009; 145: 196-203Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar,138Guthrie E. Creed F. Dawson D. et al.A controlled trial of psychological treatment for the irritable bowel syndrome.Gastroenterology. 1991; 100: 450-457Crossref PubMed Scopus (0) Google Scholar, 139Guthrie E. Creed F. Dawson et al.A randomised controlled trial of psychotherapy in patients with refractory irritable bowel syndrome.Br J Psychiatry. 1993; 163: 315-321Crossref PubMed Google Scholar, 140Creed F. Fernandes L. Guthrie E. et al.The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome.Gastroenterology. 2003; 124: 303-317Abstract Full Text PDF PubMed Scopus (336) Google Scholar RCTs; cost-effectivenessa Level of evidence for these therapies is based on use in conjunction with medical therapies, and is based primarily on patients with moderate to severe symptoms. However, given their safety and complementary nature, these therapies can be recommended for any patient at any point in treatment.b Denotes class of behavior therapy that could be called brain–gut psychotherapy. Open table in a new tab Established alterations in the hypothalamo-pituitary-adrenal axis in IBS can explain the stress-sensitive nature of symptom induction. Patients with IBS have been shown to have heightened sympathetic nervous system arousal, lower heart rate variability/vagal tone,32Cain K.C. Jarrett M.E. Burr R.L. et al.Heart rate variability is related to pain severity and predominant bowel pattern in women with irritable bowel syndrome.Neurogastroenterol Motil. 2007; 19: 110-118Crossref PubMed Scopus (0) Google Scholar,33Jarrett M.E. Burr R.L. Cain K.C. et al.Autonomic nervous system function during sleep among women with irritable bowel syndrome.Dig Dis Sci. 2008; 53: 694-703Crossref PubMed Scopus (0) Google Scholar and higher levels of circulating stress hormones (cortisol, corticotropin-releasing hormone) than healthy controls.34Chang L. The role of stress on physiologic responses and clinical symptoms in irritable bowel syndrome.Gastroenterology. 2011; 140: 761-765Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar These altered processes can, in turn, lead to mechanical and chemical stimulation of the colon and activation of the emotional motor system (perception of normal gut signals as painful) under real or perceived stress. Furthermore, patients with IBS have been shown to have reduced thickness of the prefrontal cortex, limiting their ability to ignore sensations arising from the gut,35Labus J.S. Dinov I.D. Jiang Z. et al.Irritable bowel syndrome in female patients is associated with alterations in structural brain networks.Pain. 2014; 155: 137-149Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar and that altered resting-state functional connectivity might make them more susceptible to visceral hypersensitivity; attentional bias; and hypervigilance.36Icenhour A. Witt S.T. Elsenbruch S. et al.Brain functional connectivity is associated with visceral sensitivity in women with irritable bowel syndrome.Neuroimage Clin. 2017; 15: 449-457Crossref PubMed Scopus (29) Google Scholar,37Hong J.Y. Naliboff B. Labus J.S. et al.Altered brain responses in subjects with irritable bowel syndrome during cued and uncued pain expectation.Neurogastroenterol Motil. 2016; 28: 127-138Crossref PubMed Scopus (29) Google Scholar A recent behavioral therapy trial for IBS found improvements in functional connectivity after gut-directed hypnotherapy38Simon R.A. Engstrom M. Icenhour A. et al.On functional connectivity and symptom relief after gut-directed hypnotherapy in irritable bowel syndrome: a preliminary study.J Neurogastroenterol Motil. 2019; 25: 478-479Crossref PubMed Google Scholar; the changes were associated with IBS symptom improvement, further supporting the impact of these therapies on the pathophysiology of IBS. Behavioral techniques focused on the reduction of baseline arousal of the sympathetic nervous system, as well as strategies to proactively activate the parasympathetic nervous system under acute stress, are well-justified and a core component of most brain–gut psychotherapies. Type of relaxation technique is chosen by the therapist in collaboration with the patient based on patient preference, motivation, and context in which symptoms occur. Acknowledging that levels of evidence vary, common techniques include diaphragmatic breathing, heart-rate variability biofeedback (through digital applications), progressive muscle relaxation, guided imagery, and mindfulness-based stress reduction. Gut-directed hypnotherapy also leverages relaxation techniques to induce the hypnotic state before the delivery of potent suggestions focused o