Zarmina Islam1†
Maitreyi Raman
Yasmin Nasser- 1Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- 2Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- 3Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
Introduction: Irritable bowel syndrome and fibromyalgia share similar pathophysiologic mechanisms including sensitization of peripheral and central pain pathways, autonomic dysfunction and are often co-diagnosed. Co-diagnosed patients experience increased symptom severity, mental health comorbidities, and decreased quality of life. The role of mind-body interventions, which have significant effects on central pain syndromes and autonomic dysregulation, have not been well-described in co-diagnosed patients. The aim of this state-of-the art narrative review is to explore the relationship between irritable bowel syndrome and fibromyalgia, and to evaluate the current evidence and mechanism of action of mind-body therapies in these two conditions.
Methods: The PubMed database was searched without date restrictions for articles published in English using the following keywords: fibromyalgia, irritable bowel syndrome, mind-body interventions, cognitive behavioral therapy, mindfulness based stress reduction, and yoga.
Results: Mind-body interventions resulted in improved patient-reported outcomes, and are effective for irritable bowel syndrome and fibromyalgia individually. Specifically, cognitive behavioral therapy and yoga trials showed decreased symptom severity, improved mental health, sleep and quality of life for both conditions individually, while yoga trials demonstrated similar benefits with improvements in both physical outcomes (gastrointestinal symptoms, pain/tenderness scores, insomnia, and physical functioning), mental health outcomes (anxiety, depression, gastrointestinal-specific anxiety, and catastrophizing), and quality of life, possibly due to alterations in autonomic activity.
Conclusion: Mind-body interventions especially CBT and yoga improve patient-reported outcomes in both irritable bowel syndrome and fibromyalgia individually. However, limited available data in co-diagnosed patients warrant high quality trials to better tailor programs to patient needs.
1 Introduction
Irritable Bowel Syndrome (IBS) is a prevalent disorder that affects 7–21% of the population worldwide, and 12% of Canadians (1, 2). IBS is characterized by abdominal pain and altered bowel habits and is classified according to the primary bowel habit: IBS-D (diarrhea predominant), IBS-C (constipation predominant), and IBS-M (mixed), with some patients migrating between subtypes (1, 2). The etiology of IBS is multifactorial with aberrant brain-gut interactions (1) at its core. Patients with IBS have a poor quality of life owing to the severity of gut symptoms as well as associated comorbidities, including somatic pain disorders and psychiatric disorders (1). High symptom burden in IBS is associated with lost productivity and work absenteeism, accounting for at least $20 billion a year and cost of $9,993 per patient, and 3.5 million physician visits in the United States (3–5).
Current literature suggests that a strong relationship exists between fibromyalgia (FM) and IBS (6). FM is characterized by chronic widespread pain, headaches, sleep disturbances, difficulty concentrating, depression, and fatigue (7, 8). FM has a global prevalence of 2.7% [range 2–8% (9)]. Like IBS [3:1 ratio (4)], FM is more prevalent in women compared to men [6:1 (9)]. FM costs $8,561 per patient per year in lost productivity and work absenteeism, with direct medical costs that are three times higher than in patients without FM, highlighting its significant burden (10, 11).
FM and IBS have substantial symptom overlap and are frequently co-diagnosed (6). They have common comorbidities including other functional gastrointestinal disorders, pain syndromes (12) and psychiatric conditions including depression (13), suggesting that they share a common pathogenesis. Both disorders are difficult to treat with conventional pharmacotherapies (14–16). Up to 50% of IBS patients and 91% of FM patients seek non-pharmacologic or complementary and alternative treatments to manage their symptoms (17, 18). Thus it is critical to understand how evidence-based non-pharmacologic therapies can be used to treat these disorders.
Mind-body interventions (MBI) are effective in symptom improvement, stress relief, cognitive flexibility, and improved attention and concentration, suggesting these may modify central pain pathways, and/or autonomic dysfunction in both IBS and FM (3, 19–22). It is imperative to understand how MBIs can be used as adjunctive treatments in co-diagnosed IBS and FM. The aim of this study is to review the current literature to describe the prevalence, comorbidities, and shared pathophysiology of co-diagnosed IBS and FM. We also discuss the rationale and evidence for MBI as a therapeutic strategy in these disorders. We focus on mindfulness, cognitive behavioral therapy and yoga because of their popularity among patients and the quality of available clinical studies.
2 Methodology
Our methodology consisted of a PubMed search without date restrictions for articles published in English using the following keywords: Fibromyalgia, Irritable Bowel Syndrome, Mind-body interventions, Cognitive behavioral therapy (CBT), Mindfulness based stress reduction (MBSR), and Yoga. Variations of these keywords were also used; mindfulness, MBSR, MBI, IBS, and FM/Fibromyalgia Syndrome (FMS). Both primary and secondary articles were used to synthesize this review.
3 The relationship between IBS and FM
IBS patients report symptoms of bloating, abdominal pain, and altered bowel habits such as constipation or diarrhea (1). Extraintestinal symptoms include headache, insomnia, fatigue, and palpitations (4). FM presents with unexplained musculoskeletal and widespread pain along with fatigue, sleep disturbances, and altered bowel habits (4, 6, 12). Diagnostic criteria involves assessment of defined tender points using the 2016 fibromyalgia survey with widespread pain on both sides of the body (23), although variability exists in presentations (12).
A systematic review (n = 14 studies) reported the prevalence of IBS in FM to be 32.5% (range 28–59%), whereas 73% of patients with FM reported altered bowel habits (6). Despite shared comorbidities and symptoms, the prevalence of FM in IBS has not been well-defined. There is a discordance in prevalence estimates, ranging from 48% (range 32–77%) to 12.9% (95% CI 12.7–13.1) from a systematic review (n = 30 studies) and meta-analysis (n = 65 studies), likely as a consequence of differing study designs (24, 25).
Amongst FM patients, bowel symptoms occur frequently: bloating (65.4%), abdominal pain (57.1%), fecal incontinence (56%), constipation (52.9%), alternating diarrhea and constipation (21.3%), and diarrhea alone [6% (6)]. Interestingly, FM predominates in patients with IBS-C (6). Both FM and IBS affect women more and overlap with depression, anxiety, sleep difficulties, fatigue, and chronic headaches (1, 6, 12). Psychiatric disorders are highly prevalent in both conditions. For instance, 30–50% and 30% of patients with functional gastrointestinal disorders report anxiety, and depression, respectively (26). In IBS, a prevalence of 39.1 and 23.8% exists for anxiety and depression, respectively, affecting the IBS-C type most (27, 28). Moreover, 38% of IBS patients report suicidal ideation (29). In comparison, FM has a prevalence of 32% for mood disorders, 63% for depression, with 32.5% of patients reporting suicidal ideation (13, 24, 30).
4 Common pathophysiologic basis in IBS and FM
4.1 Central sensitization and altered neurotransmission
An altered central pain state, characterized by increased neuronal excitability resulting in hyperalgesia (increased pain intensity from a painful stimulus), as well as allodynia (pain caused by a non-painful stimulus), is the first proposed common mechanism underpinning FM and IBS (31). Both FM and IBS patients show enhanced activation of ascending excitatory pain pathways, and dampening of descending inhibitory pain pathways (12, 32, 33). This results in heightened activation of central pain circuits and in the processing of negative emotions in the brain. Patients with IBS and FM individually show greater activation of brain areas associated with pain, negative emotions, memory retrieval, and attention to sensory stimuli compared to healthy participants (26, 34–37). In FM, functional MRI studies demonstrate heightened pain processing in subcortical and cortical regions in response to mild pressure that is perceived as normal touch for those without FM (38). In IBS, MRI studies demonstrate abnormal brain responses to painful visceral stimuli, such as rectal distention (39) as well as abnormal brain activity and connectivity at rest (26, 40) suggesting that abnormal central pain processing is a key component of both IBS and FM.
4.2 Somatic/visceral hypersensitivity
IBS is characterized by visceral hypersensitivity while FM is characterized by somatic hypersensitivity. Those with co-diagnosed IBS and FM show somatic hyperalgesia with lower pain thresholds and higher pain frequency and severity, whilst those with only IBS demonstrate somatic hypoalgesia (41).
Peripheral sensitization of nociceptors (pain-sensing neurons) contributes to hypersensitivity in both IBS (35) and FM (7). Peripheral nociceptors, either at the level of the gut wall, or at the level of the skin and joints, express receptors for mediators (e.g., proteases, cytokines, histamine, and bradykinin) which are released in response to cell damage or injury. These mediators can sensitize nociceptors, leading to increased neuronal excitability. In turn, nociceptors release substance P and calcitonin gene related peptide, which augment the inflammatory response at the level of the periphery and activate central pain pathways, thus contributing to central sensitization (7, 35).
4.3 Autonomic dysfunction
Both IBS and FM are associated with increased sympathetic tone and activation of the hypothalamic-pituitary-adrenal (HPA) axis, which is associated with disturbances in gut motility (6, 24, 42, 43). This suggests why MBIs may be effective for both disorders as they are thought to increase parasympathetic activity (3) and dampen sympathetic outflow.
4.4 Gut microbial dysbiosis
An altered gut microbiome is hypothesized to contribute to the pathophysiology of IBS and FM, although is more extensively characterized in IBS. Dysbiosis, or a change in the gut microbiome composition, has been shown in both disorders (44–46), with an altered Firmicutes to Bacteroidetes ratio observed at a phyla level, although the data are heterogeneous. IBS is associated with a high Firmicutes to Bacteroidetes ratio (45, 46) whereas in a study comparing 54 FM patients and 36 healthy individuals, a low Firmicutes to Bacteroidetes ratio (44) was observed. A decrease in Firmicutes has also been associated with major depressive disorder which is comorbid in IBS and FM (47). However, it is unknown whether these changes in the gut microbiome are a cause or consequence of altered gut motility. Further studies are warranted to understand the causative role of dysbiosis in both conditions.
4.5 Psychological basis
There is strong evidence that psychological comorbidities in IBS increase stress reactivity and amplify somatic sensations (24). Patients with IBS or FM report increased adverse early life events (48), a perceived lack of social support, and increased association of stressful life events to symptoms (26, 49). In addition, IBS and FM share a behavioral component called “catastrophization” (envisioning the worst possible scenario for an action or exaggerating a painful experience) which correlates with pain severity, presenting a potential therapeutic target for MBIs (1, 24).
5 Impact on quality of life
5.1 Psychological
A meta-analysis found a strong correlation between medically unexplained symptoms and increased depression/anxiety in IBS and FM (50). In IBS, a positive correlation was seen between somatic and psychiatric comorbidities, increased health care seeking, and reduced quality of life (51). Major depressive disorder is the most common psychiatric comorbidity in FM and IBS (4, 13). However, FM is characterized by lower anxiety scores than IBS (50).
5.2 Sleep and fatigue
Sleep disturbances contribute to pain, as lack of sleep impairs descending pain inhibitory pathways, impairing an individual’s ability to cope with pain (52). Sleep disorders are highly common in IBS and FM, with studies estimating a prevalence of 33% in IBS (48) and 92.9% in FM (53). More than 50% of FM patients meet criteria for insomnia; non-restorative sleep in these patients is associated with heightened pain, cognitive arousal and catastrophization (32). FM patients report morning stiffness, fatigue, and pain; hence improving the sleep quality by employing exercise is effective (54). In addition, fatigue contributes to poor health in both conditions. There is a median comorbidity of 51% for chronic fatigue syndrome in IBS and 76% in FM. Patients with comorbid chronic fatigue have 57% loss of productivity and 37% decline in household income (48, 55, 56) compared to those without. Furthermore, patients with co-diagnosed FM and IBS experience increased fatigue and symptom severity compared to those with FM or IBS alone (6). Taken together, a co-diagnosis of both FM and IBS results in significantly increased fatigue, poor sleep, and impaired quality of life, suggesting a need for therapies aimed at improving these common symptoms. Given the role of stress and anxiety in exacerbating chronic pain in both conditions, it would be important to engage patients in therapies which address these concerns.
6 Mind-body interventions
Mind-body interventions (MBI) are alternative treatment options that allow active participation of patients in their health. This is done through introspective practices that involve self-observation, meditation, relaxation exercises such as breathing, and non-judgmental acceptance of both internal (emotions, breathing, etc.) and external events (noises, smells, etc.) known as mindfulness (57). This review will focus on: (a) Mindfulness MBIs such as Mindfulness-based stress reduction, Mindfulness-Based Cognitive Therapy, Mindful Socioemotional Regulation Intervention, and Tai Chi; (b) Cognitive Behavioral Therapy (CBT); and (c) Yoga. A summary of randomized controlled trials examining MBIs for FM and IBS is found in Tables 1, 2, respectively.
Table 1. Mind-body randomized control trials for Fibromyalgia.
Table 2. Mind-body randomized control trials for IBS.
6.1 Mindfulness
Mindfulness is used to treat both IBS and FM (20, 58–66). A recent meta-analysis suggests mindfulness and acceptance-based interventions result in moderate improvements in pain, sleep, quality of life, anxiety and depression in FM (67). In IBS, a recent systematic review highlights improvements in psychological wellbeing, catastrophizing, and pain coping efficacy with mindfulness (20). Another online mindfulness trial demonstrated a significant improvement in the IBS quality of life and GI-Specific Anxiety, with 42% of intervention participants reporting decreased IBS symptoms compared to a 12% increase in controls (65). Other trials show significant improvements in IBS symptom severity, quality of life and anxiety with mindfulness therapy, compared to controls (64, 65, 68) (Table 2). Moreover, the improvement in symptom severity was maintained at a 6 month follow-up in the intervention group (64).
In FM, a web-based mindful socioemotional regulation intervention improved pain, stress coping, social engagement, and loneliness in comparison to a health education control group (20, 66) (Table 1). Another randomized controlled trial found significant decreases in stress, and sleep disturbances, suggesting those with greater at-home practice had decreased symptom severity (63). The proposed mechanisms of action of mindfulness is through decreased sympathetic outflow and HPA axis activation (57), with associated changes in brain connectivity resulting in enhanced self-regulation through the modulation of emotions, self-compassion, and body awareness (69, 70).
6.2 Cognitive behavioral therapy
Cognitive Behavioral Therapy (CBT) involves altering unhelpful patterns of thinking (cognitive bias) to alleviate stress, and improve self-regulation (68). CBT has also shown promising outcomes with reducing catastrophizing through Acceptance and Commitment Therapy. This allows participants to reflect on their thoughts and sensations, effectively reducing psychological symptoms and facilitating pain acceptance, thus improving quality of life (71, 72). Although the mechanism behind such psychological interventions is unclear, an improvement in illness-specific thoughts, beliefs and perceptions or cognitive bias has been postulated (73). In both IBS and FM, CBT results in decreased symptom severity, improved mental health and quality of life (32, 65, 68, 74–79).
The Cognitive Activation Theory of Stress hypothesizes that insomnia causes changes in the HPA axis, the central nervous system, and increases sympathetic activity, causing higher pain sensitivity (32). In turn, pain prevents restful sleep. Patients can undergo CBT specifically aimed at treating insomnia to reduce chronic arousal, improve sleep quality, and consequently pain.
In IBS, there have been four trials of CBT which reported benefits on symptom severity (65, 68, 77–79) (Table 2). A 24-month follow up comparing telephone CBT, web CBT and a treatment as usual group found greatest reduction of symptom severity in the telephone-CBT group (77). Patients receiving a 10 week course of CBT who achieved a positive response by week 4 (termed as rapid responders) experienced symptomatic reduction that was maintained at 3 month follow up (78). Similarly, a trial of CBT in female IBS patients found reduced pain catastrophizing, and improved quality of life compared to waitlist controls (68). A meta-analysis demonstrates CBT was most effective with long-term or continuous home practice (80, 81).
6.3 Yoga
Yoga combines techniques of different MBIs including breath work, movement, and meditation, showing promising benefits in chronic diseases such as cancer, IBS, as well as mental illnesses (82–84). Yoga improves balance, strength, and mobility, and allows non-judgmental observation of thoughts. Schumann et al. suggest it is a safe and feasible therapy for IBS because it improves symptom severity, quality of life, physical functioning and anxiety (85) (Table 2), however, more high quality clinical trials are needed to determine efficacy (85–92). The proposed mechanisms includes changes in autonomic outflow, as well as changes in central connectivity in the brain (69, 93–95). Moreover, breathing influences autonomic activity; in yoga, this is demonstrated through decreased sympathetic and increased parasympathetic activity (3, 59). In comparison to other therapies such as Mindfulness-based stress reduction, a low-FODMAP diet, and physical exercise (but not CBT), yoga was shown to be superior in improving quality of life, GI symptom severity and reducing stress and anxiety (3). Yoga programs inclusive of different breathing exercises, postures and meditation have beneficial effects on symptom severity in comparison to CBT; thus yoga programs with multiple modalities of mindfulness may provide more benefits (3). Although larger studies are needed, preliminary studies in adults and adolescents suggest that clinically meaningful improvement in IBS symptoms and sleep quality is experienced from yoga (86–89). However, qualitative studies demonstrate the need for better adherence strategies, social support, and yoga programs tailored for IBS (88, 89). For example, yoga delivered in a group setting was found to be more effective with engaged participants (71).
Yoga also demonstrates benefits in FM (59, 96–98) (Table 1). A trial with female FM patients comparing a Yoga Awareness program to a wait-listed control showed decreased anxiety (by 42.2%), depression (41.5%), emotional distress (30%), and fatigue (29.9%) in the intervention group (31, 59, 60). Sustained improvements were seen at 3 month follow-up, with greater impact when adhering to at-home yoga practice (59, 60). A pilot study with daily home practice showed reductions in catastrophization and pain, which were maintained at 6 month follow-up (98). A gentle Hatha Yoga program improved FM physical symptoms, assessed with the Fibromyalgia Impact Questionnaire (97). Interestingly, Yoga in combination with Tui Na massage (targeting meridians and acupuncture points on the body) showed promising results in pain reduction (96). Thus, multiple modalities of yoga demonstrate clinical benefit in FM.
7 Limitations and future directions
A strong relationship between FM and IBS is evident through their pathogenesis. The current evidence base for MBIs in the treatment of IBS and FM is growing. Studies have demonstrated multiple physical and mental health benefits, along with safety and feasibility. To our knowledge, high quality studies such as large randomized control trials assessing the efficacy of MBIs in co-diagnosed patients with IBS and FM are lacking. Therefore, we recommend that future studies testing the feasibility and efficacy of MBIs should use an active comparator groups and be tailored toward the patient to increase intervention effectiveness. Gaps in the literature include assessment of optimal MBI duration, frequency, components (single vs. multimodal) and delivery (online vs. in-person).
Our review has several limitations. First, the heterogeneity of the MBIs chosen for discussion included only the most investigated interventions among IBS and FM patients. Second, assessing MBI efficacy is challenging given the examined studies differ greatly in their methodologies. This limits the generalizability of the results, and the specific recommendations (MBI type, dose, and frequency) that can be made for co-diagnosed IBS and FM.
Until further data from high-quality trials are available to inform a definitive approach to yoga interventions in co-diagnosed patients, yoga practice involving postures, breathing, and meditation may be recommended at a dose of 30 min daily, five times weekly. These recommendations are in parallel to widely accepted physical activity guidelines and from studies that demonstrate similar integrated approach to yoga intervention and dosage achieve improved outcomes (99, 100).
Lastly, studies should also evaluate potential mechanisms of action of MBIs such as microbiome alteration, neuroendocrine/neuroimmune responses, and autonomic outflow.
8 Conclusion
Negative impacts on patient quality of life and mental health arising from comorbid FM and IBS, and limited data on co-diagnosed patients warrant study of effective interventions. MBIs such as CBT and yoga are impactful and leverage one of many potential pathophysiological mechanisms. Future interventions should aim toward tailoring yoga programs in combination with other MBIs to meet the needs of IBS and FM patients.
Author contributions
ZI drafted the manuscript. AD’S, MR, and YN critically revised the manuscript for important intellectual content. All authors have reviewed and approved the final manuscript.
Funding
This work was supported by the Canadian Institutes of Health Research and the Weston Family Microbiome Initiative (to YN).
Conflict of interest
YN has received speaker fees, honoraria, and grant funding from Abbvie/Allergan. MR has received speaker fees from Abbvie/Allergan and Lupin.
The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Abbreviations
IBS, irritable bowel syndrome; FM, fibromyalgia; MBI, mind-body interventions; HPA, hypothalamic-pituitary-adrenal axis; CBT, cognitive behavioral therapy.
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Keywords: IBS–irritable bowel syndrome, fibromyalgia (FM), mind-body interventions, yoga, cognitive behavioral therapy (CBT)
Citation: Islam Z, D’Silva A, Raman M and Nasser Y (2022) The role of mind body interventions in the treatment of irritable bowel syndrome and fibromyalgia. Front. Psychiatry 13:1076763. doi: 10.3389/fpsyt.2022.1076763
Received: 24 October 2022; Accepted: 06 December 2022;
Published: 22 December 2022.
Edited by:
Vijaya Majumdar, Swami Vivekananda Yoga Anusandhana Samsthana, IndiaReviewed by:
Octavian Vasiliu, Dr. Carol Davila University Emergency Military Central Hospital, RomaniaVijaya Kavuri, Swami Vivekananda Yoga Anusandhana Samsthana, India
Copyright © 2022 Islam, D’Silva, Raman and Nasser. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Yasmin Nasser, ✉ ynasser@ucalgary.ca
†Present address: Zarmina Islam, Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
‡These authors have contributed equally to this work