Reclaim Your Life from IBS

A Scientifically Proven CBT Plan for Relief Without Restrictive Diets

Melissa G. Hunt

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000586428
• Edition: 2
• Topic: Psychology
• Subtopic: Cognitive Behavioral Therapy (CBT)
• Index: Psychology

Reclaim Your Life from IBS teaches a number of skills that can directly reduce the impact of gastrointestinal symptoms in a person's life.

The book explores the differential diagnosis of irritable bowel syndrome (IBS) and the current scientific models of what causes IBS. It teaches the reader the cognitive model of stress management using cognitive-behavioral therapy and helps readers learn to identify their negative beliefs and reframe them more accurately. It also guides readers to reduce avoidance and helps them understand how to use dietary modifications and medications wisely, rather than reactively. In this second edition, numerous case examples throughout illustrate the application of these core CBT skills to IBS-related thoughts and experiences, and new material is included on exercise, diet, and medications.

This book is a proven self-help book for people with IBS, as well as being useful as a treatment manual for clinicians who work with patients with IBS.

1 Do I Have IBS?

DOI: 10.4324/9781032153414-2

Monica is a 28-year-old woman who works as an account representative at a midsized public relations firm. Bright, hardworking, creative, and driven, she is considered a rising star by her manager. But Monica has an awful, embarrassing problem that she works hard to keep secret from her coworkers and clients. She suffers from frequent bouts of diarrhea.

When the urge to defecate comes on her suddenly and powerfully, she is never sure she’ll make it to the bathroom on time. During these attacks, it feels like a red-hot hand has reached into her gut, grabbed her intestines, and tied them into knots. The burning, cramping pain is so agonizing it can bring tears to her eyes. The urgency is so intense, she fears losing control of her bowels altogether and soiling herself. The only thing that brings relief from the pain is defecating. It’s manageable when it happens at home and she can simply run to the bathroom. But she fears having an attack when she is on the road or when she is trapped in a meeting at work.

She knows stress makes it worse. There was the time she was scheduled to present a new campaign concept to an important client, and she spent the entire morning at home on and off the toilet. She almost called in sick but ended up making it to the meeting with only minutes to spare.

She has tried a range of remedies, dietary changes, and over-the-counter medications. Her doctor had her try two rounds of antibiotics to see if she had small intestinal bacterial overgrowth (SIBO) but it didn’t help at all. She stopped drinking milk and switched to soy milk. Unfortunately, her cramping and diarrhea symptoms didn’t change, though she did seem to get more gas. Her doctor recommended eating more fiber, but she found that fiber supplements gave her terrible gas and seemed to make her symptoms worse, especially if she took the full dose recommended on the package. Then she tried eliminating gluten, but it didn’t seem to make a difference to her symptoms. Her doctor gave her a handout about the low FODMAP diet, and she started trying to follow it. She definitely experienced some relief from her gastrointestinal (GI) symptoms, but she found it so restrictive and difficult to adhere to, she gave up on it. She still religiously avoids onions and garlic, which makes it very difficult to eat out or go to a friend’s house for dinner, and she lives in fear of eating something that will trigger terrible spasms and urgency. Imodium gives her some relief and she’ll pop one or two pills on the morning of a particularly busy or difficult day at work. Recently, she has started to carry Lomotil tabs in her purse for emergencies and will take it if she feels the twinges or spasms that often herald an attack. However, this sometimes leads to several days of no bowel movements at all. While this can be a relief for a few days, the end result of this is often constipation and bloating. She’ll strain and push trying to have a bowel movement and she’s developed some painful, itchy hemorrhoids as a result. If she still can’t go, she’ll take a few doses of Miralax, and then stay home until it works. When she finally gets the urge to go again, it is often urgent and explosive. Sometimes the hemorrhoids bleed when she defecates, and seeing the bright red blood in the toilet is terrifying. She can’t believe that her doctor can’t find anything physically wrong with her, and she keeps wondering if they missed something serious.

All in all, Monica is sick of the constant merry-go-round of diarrhea and constipation, sick of the pain and fear of being too far from a bathroom, and desperate for some relief.

If Monica’s story sounds all too familiar to you, you may have IBS. Irritable bowel syndrome is a condition in which people experience recurrent abdominal pain (at least 4 days a month or once a week), along with a change in how often they defecate and/or a change in the form of the stool itself. For most people, the pain or discomfort is associated with (and often relieved by) defecation.

As you may know, IBS is often hard to diagnose. There are two reasons for this. First, two of the main symptoms of IBS (abdominal pain and diarrhea) are common to a number of other disorders as well. The second reason IBS may be hard to diagnose is that there are no tests for it. You can’t see it on an X-ray, a CT scan, or an MRI. You can’t detect it in blood work. Your doctor wouldn’t be able to see inflammation or polyps (little abnormal, fleshy growths) or lesions if he or she did a colonoscopy or an endoscopy. In fact, your bowels, or intestines, will appear perfectly normal across a range of diagnostic exams and tests. Nevertheless, they don’t seem to work, or function, in a way that is smooth, painless, and efficient – that is to say, normally. This distinguishes IBS from other problems, such as inflammatory bowel diseases (IBDs) or celiac disease in which doctors can observe pathological changes in the tissues of the intestines.

Before a doctor diagnoses you with IBS they will want to be sure that you don’t have one of these other conditions. In some cases, this can be done by simply reviewing your symptoms with you in detail. The doctor will need to know when your symptoms started, whether the symptoms come and go, where the pain is, what it feels like, and so on. The doctor will want to do an abdominal exam in which he or she will palpate, or feel, your abdomen with his or her hands. The doctor will also want to do some basic blood work to rule out things like infection and anemia. If the doctor is still not sure whether you have IBS or some other medical condition, the doctor may order more extensive tests, including more blood work (to check for celiac disease), imaging studies like X-rays or CT scans (to check for diverticulitis), and a fecal occult test (to check for blood in your stool). If you have any “alarm” symptoms (e.g., fever, pain that wakes you up at night, an elevated white blood cell count in your blood work, blood in your stool), your doctor may well order another stool test to check for fecal calprotectin (which is a sign of inflammation) or a colonoscopy, a sigmoidoscopy, or an endoscopy in which the doctor can actually take a look at parts of the intestines and even take small tissue samples, or biopsies. While these tests may seem time-consuming, invasive, and uncomfortable, it’s very important to be sure you’ve ruled out the alternative diagnoses before concluding with certainty that you have IBS. Many of these other disorders have serious complications that can result in long-term damage to your body if they’re not treated appropriately. So, the first step in fixing your GI problems is being sure you’ve got the right diagnosis. If all these other tests come back negative, then you probably do have IBS.

But just because all those tests came back negative does not mean that there is not something physically wrong. There is! IBS is a real and treatable condition in its own right. It is definitely not “all in your head.” IBS used to be classed with the “functional” GI disorders, because the only problem we could identify for sure is that the GI system isn’t functioning normally. Fortunately, we now have a much better understanding of some of the underlying causes and mechanisms of IBS. IBS is now considered a disorder of gut–brain interaction, and we know that one of the main problems in IBS is abnormal centralized pain processing. That is, the central nervous system (in the brain) and the enteric nervous system (in the gut) are inappropriately amplifying pain signals and sending messages back and forth that increase pain and can cause distension, cramping, tightening, and all the other problems that lead to increased discomfort, urgency, constipation, and abnormal bowel movements. See Chapter 2 for a comprehensive discussion of the causes of IBS.

The Rome Foundation, an independent, not-for-profit organization dedicated to research and education about functional gastrointestinal disorders, has published the following criteria for diagnosing irritable bowel syndrome.

ROME IV Diagnostic Criteria for Irritable Bowel Syndrome

Recurrent abdominal pain, on average at least one day per week, in the last three months associated with two or more of the following:

1. Related to defecation
2. Associated with a change in frequency of stool
3. Associated with a change in form (appearance) of stool

If you’re a woman, the pain does not occur only during your menstrual cycle. Some people with IBS experience mostly diarrhea (diarrhea-predominant IBS) and some people experience mostly constipation (constipation-predominant IBS), but many people with IBS actually have both hard and loose stools over periods of hours, days, or weeks (mixed-type IBS), and some folks don’t have very much of either diarrhea or constipation (unspecified type IBS). Other kinds of discomfort are also associated with IBS, including:

• Feeling “gassy” or “bloated” (which sometimes results in flatulence or farting)
• Feeling a sudden urge to have a bowel movement
• Straining during defecation
• Feeling as if you “can’t get it all out”
• Having fewer than three bowel movements a week
• Having more than three bowel movements a day

The funny thing about these symptoms is that lots of people who don’t have IBS (or any other GI disorder) experience these symptoms, too, at least sometimes. That is, there’s a big range of what people consider “normal” in their bowel habits. What seems to distinguish people who have IBS from people who don’t is the severity and frequency of GI symptoms. But it’s also important to take into account how distressing the symptoms are to you and how much you feel you are impaired by the symptoms as you try to go about your normal life.

Two similar diagnoses based on Rome IV criteria are called functional diarrhea and functional constipation. The main difference is that people with those diagnoses don’t tend to experience as much abdominal pain, but they still have very disordered defecation and may feel very frustrated and impaired. This is more of a technical distinction and probably shouldn’t worry you. Even if you don’t quite meet Rome IV criteria (say because you experience pain less frequently) the treatment program in this book should still work just fine.

Many physicians now feel comfortable diagnosing IBS on the basis of a review of symptoms, an abdominal exam, and a few simple medical tests, such as blood work to rule out infection and anemia, and a stool test to check for blood. If you don’t have any “alarm” symptoms (like fever, blood in your stool, an elevated white blood cell count, anemia or other nutritional deficiencies, or abdominal pain that awakens you at night), current medical practice is to avoid further invasive diagnostic testing, because it is statistically unlikely that you will have a more serious condition. This is especially true if you are relatively young (under 50), and have no family history of colon cancer or inflammatory bowel diseases. However, it is important to keep in mind that many medical conditions, some of which are easy to manage if you know you have them, share symptoms with IBS. In particular, it is probably worth being tested for celiac disease. If you do have IBS, the treatment and skills outlined in this workbook should be very helpful to you. If you have one of these other conditions, you need to follow up with a gastroenterologist. That doesn’t mean these skills won’t help – they probably will, especially if you have secondary IBS – but you need to be sure the medical condition is also being appropriately managed.

Other Conditions That May Share Symptoms With IBS

Diarrhea and abdominal pain, in particular, can occur in a range of gastrointestinal diseases and conditions, so it is very important to consult with your physician to be confident that you have ruled them out. Conditions that share symptoms with IBS fall into several basic categories. These include inflammatory bowel diseases, celiac disease, bile acid diarrhea, pancreatic insufficiency, diverticulitis, cancer (which is extremely rare), and intestinal parasites.

To complicate matters a bit more, it is actually possible to develop IBS in addition to or shortly after experiencing some other condition. For example, it is not uncommon for people to develop what is called post-infectious IBS. This means that the person had a serious GI infection of some kind – food poisoning, a bad stomach virus, or a C-difficile (Clostridium difficile, often referred to as C-diff) bacterial infection. In these cases, there is a clear infectious agent – a bacteria or a virus that causes acute symptom...