Anxiety And IBS: In-depth Guide To Symptoms and reliable Treatments.
MD, Assistant lecturer of internal medicine, Gastro-enterology, & Hepatology.
IBS sufferer, Gut health enthusiast, and writer.
Your health matters, my content is not a substitute for the medical advice by your doctor. #Stay_Safe
Anxiety and IBS:
Anxiety And IBS Symptoms And Relations.
Let’s define things: Anxiety vs Stress.
Anxiety and stress are different (Although both can trigger IBS). but anxiety is something more than stress.
Stress is your body reaction to External “stressors”. with anxiety, there is something that is coming from inside. And it is not leaving.
With anxiety, the feeling of worries and uneasiness of what is happening or what is to come is continuous. Even though there are no actual stressors from outside.
According to the National Institue of mental health (NIMH), anxiety affects approximately 18% of American adults.
Another study estimate that anxiety disorders affect one-third of the population!
Anxiety is a spectrum of diseases that vary in severity:
- Generalized anxiety disorders: long-lasting fear and worry that is not related to specific situations or objects. It is a common form of anxiety.
- Specific phobias: fear and worry are triggered by a specific object or situation. For example, fear of heights or high way driving.
- Panic disorders: a more intense form of anxiety, when the person experiences fear or discomfort that abruptly rises within less than 10 minutes and lasts for hours.
- Social anxiety: intense fear of social situations and social interactions.
- Post-traumatic stress disorder: although it is no longer categorized as an anxiety disorder, I personally still see lots of IBS patients with PTSD. it occurs after exposure to extreme situations like war or rape.
Any of the above varieties of anxiety disorders can be associated with your IBS.
How Anxiety And IBS Affect Each Other?
The anxiety and your IBS are closely related. Psychological stress is one of the most important mechanisms that may be causing your IBS.
This study estimates that approximately 44% of people with IBS suffer from psychological problems. This is far more common than people without IBS (only 8%).
Although the causes of IBS are not clear, the stress and anxiety play a major role. both anxiety and IBS can aggravate each other, and here is how:
Anxiety can cause and worsen your IBS.
If you suffer from anxiety for any reason, your brain will react by sending signals to your gut.
signals may be in the form of direct nerve impulses or through the release of chemicals that affects your colon function.
These brain signals may cause:
- Alternation of your pain thresholds: AKA you will feel gut pain even with very mild increases in your gut motility or gas.
- Alternation of your gut motility: anxiety may speed up (or slow down) the contractions inside your colon. thus you will feel pain and you may experience diarrhea or constipation.
- Alternation of your gut bacteria: the bacteria inside your gut plays an important role in digestion and healthy colon. your brain anxiety may release chemicals that alter the composition of your gut microbes. this will trigger your IBS symptoms.
- Inducing real inflammation: some theories suggest that stress alters your immunity, so inflammation occurs inside your colon.
IBS attacks can also increase anxiety.
If you have IBS, this can cause or aggravate anxiety through 2 main mechanisms:
- Your gut may release some chemicals that affect your brain: your gut release about 90% of the serotonin inside your body. changes in your body’s serotonin level greatly affect your brain mood and may cause anxiety.
- Over-thinking about your gut: Your IBS symptoms are nonspecific. It can occur with other types of potentially dangerous diseases like Crohn’s disease or even colon cancer. These IBS symptoms may be confused as a danger to your health. Thus it may cause anxiety.
Which came first; IBS or anxiety?
Although the strong evidence of the relationship between anxiety and IBS, there are no clear explanations about who came first.
not all people with anxiety have IBS & also, not all people with IBS have anxiety.
I think both scenarios could happen. but more commonly, anxiety is more to come first causing your IBS symptoms.
If you don’t know whether you have IBS because of your anxiety or you have anxiety because of your IBS, Try to apply the below scenarios to your condition. And you may conclude specific to your condition.
Anxiety may be the cause of your IBS if:
- You have a stressful childhood with a history of child abuse or any bad events.
- You have chronic stressful work conditions or financial insecurity.
- If your IBS started after a traumatic emotional event in your life (like loss of a beloved one).
- If your IBS usually flares up in stressful situations like exams.
IBS may be the cause of your anxiety if:
- You experience anxiety only after the IBS attack starts.
- You are not confident about your IBS diagnosis (suspecting that you have a dangerous health problem).
General symptoms & effects of Anxiety on your Body.
Anxiety not only affects your IBS but also it influences your entire body. Here, I will introduce to you the most important symptoms and effects of anxiety on your body.
1– Irrational fears and worrying.
Fear and worrying even from normal daily events is the hallmark of anxiety. it may become severe enough to continue for months. this worrying may interfere with your life and daily activities.
2- Restlessness and Fatigue.
if you feel chronically fatigued and restless. this may indicate that you have a real anxiety disorder. the common symptoms associated with anxiety include:
- rapid heartbeats.
- fast breathing.
- Inability to perform daily activities.
3- Lack of concentration and sleep problems.
Chronic stress may impair your concentration during studying or work. and also may cause you sleeping problems like trouble falling asleep or staying asleep (insomnia).
4- Headache and chronic pain anywhere in your body.
5- Increases the risk of heart problems and hypertension.
6- May lead to depression, a more serious problem
Anxiety and IBS symptoms.
1- Presence of general anxiety symptoms: It is the cardinal feature suggesting that Anxiety plays a central role in your IBS. You may experience irrational fears and worry during your IBS flare-ups.
Also, other severe anxiety symptoms may exist during the IBS attack as irritability, insomnia, and generalized fatigue of your body. Even panic attacks with sweating, irritability, and a sense of extreme fear may accompany your IBS attacks.
2- Timing of IBS attacks: one important feature of IBS/anxiety is the relation of the onset of your IBS attack to anxiety. Meaning that whenever you experience an anxiety attack (either due to true stress or irrational fear), Your IBS attack will consequently start.
- Your IBS attack starts when you are in a stressful situation like an exam.
- Your IBS attack starts after you experience unexplained fear or phobia.
3- Atypical IBS symptoms: lots of Atypical symptoms you may experience during IBS attacks can be assigned to anxiety. Examples:
- Difficulty breathing.
- atypical IBS pain locations: for example, IBS back pain and pelvic pain.
4- Constipation or diarrhea: some studies relate anxiety to IBS-Diarrhea, others related it to IBS-Constipation. Although the slight predominance of IBS diarrhea with anxiety. but all types of IBS (IBS-Constipation, IBS-Diarrhea, and IBS-Mixed) can occur.
5- Bloating and distension: Bloating (visible distension of your abdomen) is frequently experienced in people with IBS and anxiety. typically, if you are an “anxious person”, your pain threshold is low. so, any small amounts of gas and bloating can be problematic to you.
Also, if you are a female, bloating can be a source of anxiety alone (as it alters your body shape).
When To Ask for Help?
Can I have anxiety while I am unaware of it?
Yes, most of us may have some sort of hidden anxiety affecting our IBS. your mind and body are under stress. And this may affect your thoughts and self-awareness. You will have anxiety symptoms without even knowing that you are anxious.
Stop and think about what thoughts are running in your mind. Also, talk to your close friends or your partner about your mood, attitude, and the effect of stress in your life.
And I strongly recommend talking to your GP or Gastroenterologist about the possible role of anxiety in your IBS.
How to assess your anxiety Using GAD-7 score:
fortunately, a simple score to assess the presence of anxiety, and its degree is present. you can do it yourself, but take care:
- This score is NOT a replacement for medical advice by your doctor. If you think you have a serious psychological problem you have to talk to your health care provider.
- This score is only for screening. It does not apply to all types of anxiety.
- Use it to know if you need medical help for anxiety or not.
The score consists of 7 questions. each question is answered with one of 4 possible answers (shown in the image below). according to your answer number of points (from all 7 questions) will give you an idea about the degree of your anxiety.
The 7 questions to ask yourself are:
1- Do I feel nervous, anxious, or on the edge?
2- Am I not able to stop or control worrying?
3- Am I worrying too much about everything?
4- Do I have trouble relaxing?
5- Am I so restless that it is hard to sit still?
6- Do I become easily annoyed or irritable?
7- Do I feel afraid as if something awful might happen?
For all questions, answer with one of the following:
- Not at all = 0
- Several days = +1
- More than half the days = +2
- Nearly every day = +3
After you answer all questions, collect the points then assess your anxiety score as the following:
- A score from 5-9: Mild Anxiety.
- A score from 10-14: Moderate anxiety.
- A score of 15 or more: Severe anxiety.
You can take the test HERE
I included this test to help you initially evaluate yourself for anxiety. If you think you have any forms of anxiety talk to your doctor for further evaluation and best management.
IF you think anxiety is worsening your IBS, I included a review of the best treatments that helps you to deal with this condition.
How To Deal With Anxiety And IBS
(Effective & Reliable Treatments)
Must-Do things before you try IBS anxiety treatments.
Before we discuss different options to deal with your anxiety and IBS, You have to remember some important issues:
1- Only try these treatments after discussing the issue with your doctor.
You can’t deal with anxiety on your own. presence of anxiety usually means you need help. working with your doctor to define the presence and the impact of anxiety on your IBS is vital.
2- Only try these treatments only after failure of usual IBS treatments.
Simple treatments like antispasmodics, antidiarrheals, or anti-constipation medications whether over-the-counter or prescription can control your IBS. If the usual treatment and diet control measurements fail, it is worth trying the below treatments.
3- Always try non-pharmacological treatments before medications.
Non-pharmacological treatments like Cognitive behavioral therapy, relaxation therapy, and hypnotherapy are safer with fewer side effects, and less costly. Also, they may be effective for your anxiety more than medications.
4- Make sure that you have Actual anxiety.
Thoroughly read part one of this guide, Test your self with the GAD-7 score, and consult your doctor.
5- Understand that there No single treatment is 100% effective.
Till this moment, We couldn’t find a definite cause or treatment for IBS. any treatment for IBS itself or anxiety may have failure rates. What works for you may not work for me and vice versa. What you can do is trying different treatments (in the right order and the right way). And you will figure out what works for you and what is not working.
6- For better results, you can combine more than one of the treatments mentioned below.
Learn to build self-esteem & to be assertive.
If you have anxiety, mostly you will also have “self-esteem” issues.
People with low self-esteem tend to have a distorted picture of themselves. Sense of inferiority and consistent negative expectations about yourself will cause anxiety and IBS.
This study demonstrates that people with IBS have significantly lower self-esteem than other non-IBS sufferers.
Signs that you may have low self-esteem:
1- feeling unworthy or inferior.
2- being a perfectionist and not accepting criticism.
3- Overly critical to yourself and others.
4- Inability to express your feelings to others.
5- Fear of change or new experiences, constantly depending on others.
All these issues lying deep in your mind may be the cause of your anxiety and IBS. Dealing with your self-esteem may be the first “real” step to overcome your IBS.
Powerful Tips to regain your self-esteem:
1- Be assertive: Having clear thoughts about yourself, your needs, and your opinion is vital for your self-esteem. Being assertive is the first step to regain your self-esteem. And this consequently is the first step to control your IBS and anxiety.
2- Be kind to yourself: Notice the moments that you are overly critical to yourself. Be kind to YOURSELF and accept that being “not-perfect” doesn’t mean you are “bad”.
3- Learn to say “NO”: The sense of inferiority makes you over-estimate others’ reactions and feelings towards our actions. learning to say NO to the things that against your needs or beliefs help you to regain your self-esteem.
4- Ask others for help: speak out about your problems with a close person.
5- Try cognitive behavioral therapy: see below.
Breaking the circle of low self-esteem-anxiety will greatly help your IBS.
Learn more about self-esteem:
Cognitive Behavioral Therapy (CBT): One of the most effective treatments for IBS and anxiety.
What is Cognitive Behavioral Therapy?
CBT is originally developed for the treatment of psychological diseases like anxiety and depression. CBT is well established and proved to be very effective for IBS, especially if you have IBS and Anxiety.
The idea behind CBT: Our thoughts (the way we view different events) greatly determines what we behave and feel.
An event or situation >> thoughts >> behavior and feelings.
CBT is a technique used by a therapist to help you to identify your destructive thoughts (COGNITIVE) and their impact on your feeling and behavior (BEHAVIORAL). And He (the therapist) actively educates you on the skills and methods to change your thoughts and behavior (THERAPY). This will result in a dramatic improvement in your anxiety and IBS.
Is CBT for IBS effective? (evidence studies)
Yes, To the degree that I consider it “One of the best treatment options for people with IBS & anxiety”.
In 2107, A review study published in “psychology research and behavior medicine” journal about CBT for IBS, concluded that CBT consistently demonstrates significant and durable effects on IBS symptoms and quality of life.
Source: a Review study
When should you try CBT for your IBS?
I suggest you try CBT only if:
1- You failed to control your IBS with medications for a long time.
2- You Think that IBS is greatly affected by your anxiety or stress.
3- You discussed the efficacy of CBT with your doctor.
4- IBS drugs cause side effects to the degree you can’t tolerate.
What is the best way to do CBT for IBS?
There are many options for Cognitive behavioral therapy:
1- with a therapist (face to face).
2- Telephone-based or online (telepsychology): the telepsychology is proved in research that is equally effective to conventional face-to-face. Even the “American psychological association” has guidelines for it.
3- By yourself: using self-help books and apps. (which I don’t recommend)
So, What is the best way?
The best way to obtain CBT for your IBS and anxiety is through a local certified Cognitive-behavioral therapist. The therapist should have a special experience in functional GI disorders.
Although it is harder for some people to find time and money for “Face-To-Face” therapy, It still the best method to benefit from CBT.
But If you don’t have time or don’t find the right therapist, the good news is that “the Online CBT is as effective as direct CBT. Also, it has some advantages for people who want easy access at any time or any place.
Another 2 pros of online CBT are that it is less overwhelming for those who don’t like to be completely open to a stranger in a “face to face” situation. and it is at a much lower cost.
Sponsored Content That you may love:
you can try “online-therapy.com“. One of the best online programs specialized in “CBT” with a complete toolbox, videos, and yoga courses. their therapists are top in the industry and some of them are celebrities like Dr. Elizabeth Lombardo, Ph.D.
What I don’t recommend is practicing Cognitive behavioral therapy by yourself. Pursuing CBT using self-help guides may fail to have the desired results. And more importantly, you will lose “Faith” in CBT as an effective treatment.
How Effective is Hypnotherapy for IBS and anxiety?
Gut-directed hypnotherapy for IBS has been tested in clinical trials. And showed efficacy in relieving your IBS and anxiety.
A recent clinical trial compared the short-term and long-term efficacy of gut-directed hypnotherapy and the low-FODMAP diet. The study found similar durable effects for the relief of GI symptoms.
Hypnotherapy can be done by either 2 ways:
1- Session with a specialized hypnotherapist (Gut Directed).
2- Using online audio programs.
Both methods of hypnotherapy work. But sessions with a professional state-licensed hypnotherapist is best. Some Health insurance plans cover Hypnotherapy sessions. discuss the issue with your doctor.
Many benefits have been noted with hypnotherapy:
- Overall improvement of IBS symptoms that can last for long periods. (in Up to 75% for people with IBS)
- Improvement of your well-being and anxiety.
- Relieves abdominal pain and bloating, may help with diarrhea and constipation.
- Especially helpful in people with anxiety.
- Help with atypical IBS symptoms like fatigue, nausea, back pain, and urinary symptoms.
Where to find Board-certified clinical hypnotherapists:
Use this Database to search for certified hypnotherapists in your country.
Some studies showed the benefits of relation therapy to relieve IBS anxiety. this Review study showed positive effects on your IBS.
However. the scientific evidence is not very strong due to the small number of study participants and the difficulty in interpreting the results .
although the results of relaxation therapy are not typical for everyone, you can give it a try. Just choose one or more of techniques enlisted below and stick to it to see results. Just Don’t quit too early.
- Diaphragmatic/abdominal breathing exercises: learn more.
- Progressive muscle relaxation.
- Visualizations – positive imagery.
To learn more about relaxation techniques, read this insightful article.
Anti-anxiety medications prescribed by your doctor:
the 2 most common groups of medications include:
- Tricyclic Antidepressants: such as Amitryptiline.
- Selective Serotonin Reuptake Inhibitors (SSRIs): such as Alosetron.
You cannot take these medications on your own. you must consult your doctor about the use of these medications. and only use them after the failure of other simple techniques enlisted here.
we will discuss them in a later article.