IBS and Anxiety: Managing the Connection for Better Health

What is Irritable Bowel Syndrome (IBS)?

Irritable bowel syndrome (IBS) is a term used to describe a group of long-lasting gastrointestinal symptoms, including chronic abdominal pain and abnormal bowel habits. Systematic review and meta-analysis have shown that the global prevalence of irritable bowel syndrome is about 11%, varying widely based on geographical location. 

Although IBS can be an extremely uncomfortable condition to live with, it does not permanently damage the digestive tract or increase the risk of colon cancer. Lifestyle changes, including dietary modifications and behavioral therapy, are the cornerstone of IBS treatment. Your doctor may also prescribe medications to treat the symptoms associated with IBS to improve your quality of life.

Common IBS Symptoms

Irritable bowel syndrome patients commonly experience GI symptoms like abdominal pain and cramps, excess gas and bloating, and alterations in bowel habits (frequent bouts of diarrhea, constipation, or both). Learn more: “What Does IBS Pain Feel Like?”

Causes of Irritable Bowel Syndrome (IBS)

We don’t know exactly what causes IBS, but it is classified as a neurogastrointestinal disorder because it occurs due to problems with the gut-brain axis. This is a channel of communication between the brain and the gut that regulates gut function. Miscommunication in the gut-brain axis results in dysmotility (gut muscle contractions and movement of food through the digestive system) and visceral hypersensitivity (overly sensitive nerves in the GI tract).

Other possible causes of IBS include alterations in the gut microbiome (the balance between helpful and harmful bacteria in the intestines), severe infections, food allergies and intolerances due to an overactive immune system, and childhood psychological distress, for example, from sexual or emotional abuse.

What is Anxiety?

Anxiety is a condition associated with many mental health disorders. It is defined as the feeling of nervousness or being on edge and not being able to stop or control worrying. Feeling anxious can be a normal temporary reaction to stressors, such as taking an exam, starting a new job, or making an important decision. However, for some people with anxiety disorders, the fear does not go away and can get worse over time. People with anxiety disorders are at higher risk for developing IBS, and individuals with IBS may also experience varying levels of anxiety.

Symptoms of Common Anxiety Disorders

• Generalized anxiety disorder (GAD) causes excessive worry about ordinary life issues such as health, family, work, and money. 

• Panic disorder is associated with panic attacks, which are short periods of overwhelming fear that occur in the absence of any real danger, along with physical symptoms such as a fast heartbeat and sweating.  

• Phobias are intense fears of specific things that aren’t actually dangerous, for example, spiders, crowded places, or social situations.

The Gut-Brain Connection

Scientific evidence suggests that the gut and brain in the human body have a bidirectional connection called the gut-brain axis. The presence of the brain-gut axis means that changes in the gut can affect the brain, and changes in the brain can affect the gut. While the brain regulates every part of the body through nerves, the connection between the brain and the gut is believed to be stronger than any other system in the body. The gut also has more nerve cells than any other organ system.

If you’ve ever had a “gut feeling” about something, found an experience “gut-wrenching,” or felt “butterflies in your stomach,” you’ve experienced the gut-brain connection firsthand.

The communication between the brain and the gut can affect various things like hunger, satiety, food cravings, food choices, food intolerances, digestion, gut motility, metabolism, mood, behavior, stress response, pain perception, pain sensitivity, immunity, and cognitive function.

Role of Emotions in IBS

Research shows that dysregulation of the gut-brain axis causes irritable bowel syndrome. Chronic stress, anxiety, and depression can disrupt the brain-gut axis and contribute to the development of IBS. Mental health disorders can also affect gastrointestinal symptom severity and response to IBS treatment. 

In addition to psychological factors, researchers have identified a genetic predisposition to IBS. There is also a link between physiological and psychological stressors in early life and developing IBS in later life. Scientists believe successive exposures to stress can trigger and worsen IBS symptoms. In addition, evidence suggests that effectively managing anxiety can provide relief from IBS symptoms. 

Common Triggers for IBS

• Food: Although a true food allergy is rarely the trigger for irritable bowel syndrome, certain foods and beverages can worsen the common symptoms of IBS.

• Stress: Although stress is not a direct cause of IBS, most people with IBS experience worsening of their symptoms during periods of stress and anxiety.

Common Triggers for Anxiety and Depression

Anxiety symptoms can be triggered by health issues, financial problems, family and relationship difficulties, and stressful life events such as divorce, illness, job loss, or the death of a loved one.

Is There a Link Between IBS and Anxiety?

Yes, research has established a link between IBS and anxiety. Studies have found that about 38% of people with IBS have anxiety, and around 27% of IBS patients have mood disorders like depression. These numbers are double the rate compared to healthy controls who don’t have IBS. In addition to anxiety and depression, other mental health disorders such as bipolar disorder, eating disorders, and suicidal ideation are also more common in people with IBS.

Does Anxiety Cause IBS?

Anxiety can cause worsening symptoms in people with IBS. This is because psychological stress, anxiety, and depression can trigger the firing of nerve cells in the intestines (the intestines have one of the highest concentrations of nerve cells in the body outside the central nervous system). Increased nerve impulses in the microbiota-gut-brain -axis can worsen IBS symptoms.

Can IBS Cause Severe Anxiety?

IBS can cause anxiety and depression in some people. As noted, IBS is a chronic condition that impacts daily life and needs to be managed long-term. Some studies have found that 4 out of 10 IBS patients with severe symptoms have anxiety, and 8 out of 10 IBS patients have depression. 

What is the Anxiety Cycle of IBS? 

IBS can worsen anxiety, and anxiety can worsen IBS. This can become a vicious cycle where each condition causes the worsening of the other. As mentioned, evidence suggests this occurs because of a dysfunction in the brain-gut axis (genetic pathways), which are bidirectional communication channels. As a result, IBS symptoms influence anxiety and depression, and mental health comorbidity can cause IBS symptoms. Therefore, concurrent IBS and anxiety treatment is necessary to manage these conditions.

Managing IBS and Anxiety

Diet and Lifestyle Changes 

Mild symptoms of IBS can be controlled by managing stress and making lifestyle changes such as: 

• Avoiding food triggers

• Eating a high-fiber diet

• Drinking plenty of water

• Exercising regularly

• Getting enough sleep

Eliminating certain foods from your diet can help in managing IBS symptoms:

• Foods and beverages that can cause gas and bloating, such as beans, broccoli, carbonated beverages, and beer. 

• A gluten-free diet (eliminating wheat, rye, and barley) may help people with frequent bowel movements or IBS-D.

• Low FODMAP diet - Certain carbohydrates found in some grains, fruits, vegetables, and dairy products may worsen IBS symptoms and might be helpful to avoid.

Behavioral Therapies

Cognitive behavioral therapy (CBT) can be provided by a trained mental health professional. This is an evidence-based intervention for mental health conditions such as anxiety and depression. It can be helpful in managing psychological distress, anxiety, and depression, which are known triggers for worsening IBS symptoms. A mental health provider can deliver CBT in individual, group, face-to-face, and online formats.

In addition to cognitive behavior therapy (CBT), other types of psychotherapy, such as relaxation therapy, gut-directed hypnotherapy, and dynamic psychotherapy, have also been found to be effective in treating gastrointestinal disorders like IBS.

Treatment Options: What Medication is Good for Anxiety with IBS? 

Medications for anxiety and IBS depend on the predominant symptoms. They may include:

• Fiber supplements such as psyllium (Metamucil) for IBS symptoms such as stomach pain, bloating, and constipation. 

• Laxatives such as polyethylene glycol (Miralax) and magnesium hydroxide (Milk of Magnesia) for constipation.

• Anti-diarrhea medications such as loperamide (Imodium A-D) for frequent bowel movements (diarrhea) in people with IBS-D. 

• Bile acid binders such as colestipol (Colestid), cholestyramine (Prevalite), and colesevelam (Welchol) to control diarrhea. 

• Anticholinergic drugs such as dicyclomine (Bentyl) to relieve abdominal pain from bowel spasms. 

• Tricyclic antidepressants such as amitriptyline (Elavil),  imipramine (Tofranil), nortriptyline (Pamelor), and desipramine (Norpramin) to relieve depression and pain.

• Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Paxil) and fluoxetine (Prozac) or to help with anxiety and depression. 

• Pain medications such as pregabalin (Lyrica) and gabapentin (Neurontin) to ease pain related to abdominal bloating. 

Note: Fecal microbiota transplantation (FMT) is an investigational procedure for IBS. It involves transplanting stool from a healthy individual to restore a healthy balance in an IBS patient’s digestive tract.

Specific Medical Treatment for IBS

The following medications have been approved for treating IBS:

• Alosetron (Lotronex) reduces muscle contractions in the colon and slows the movement of waste material through the lower GI tract. It is prescribed to women with IBS-D (diarrhea-predominant) who are unresponsive to other treatments. 

• Rifaximin (Xifaxan) is an antibiotic that decreases bacterial overgrowth and relieves diarrhea.

• Eluxadoline (Viberzi) eases diarrhea by decreasing fluid secretion, reducing muscle contractions, and increasing rectal muscle tone. 

• Lubiprostone (Amitiza) increases fluid secretion in the small intestine and helps women with severe IBS-C (constipation-predominant IBS) that is unresponsive to other treatments.

• Linaclotide (Linzess) increases fluid secretion in the small intestine and eases the passage of stool.

Managing Stress: How To Stop IBS Due To Anxiety?

As mentioned above, stress and anxiety are risk factors for IBS flare-ups. You can manage stress levels and lower your risk of worsening IBS symptoms with the following strategies:

• Regular exercise, preferably outdoors

• Relaxation training such as deep breathing, progressive muscle relaxation, yoga, tai-chi, meditation, and mindfulness-based practices

• Alternative treatments like acupuncture and acupressure

• Gut-directed hypnotherapy for deep relaxation

• Talk therapy, such as cognitive behavior therapy (CBT)

Tips for Calming an Anxiety-Induced Flare-up

• Practice deep breathing.

• Try to maintain your normal routine.

• Do some light exercise to keep your mood and energy levels up.

• Eat a healthy diet for overall well-being.

• Don’t completely avoid things that make you anxious—rather, try to slowly build up tolerance to anxiety triggers.

• Do not use alcohol or drugs to relieve anxiety.

When to Seek Professional Help

Call your healthcare provider if you have: 

• Persistent changes in bowel habits.

• Abdominal pain that isn’t relieved by passing gas or having a bowel movement.

• Diarrhea that lasts for more than 2 days without improvement.

• Unexplained vomiting.

• Weight loss.

• Rectal bleeding.

• Low iron (anemia).

Treatment for irritable bowel syndrome is typically provided by a primary care doctor or gastroenterologist (a health professional who specializes in digestive system disorders). However, it is important to consider the role of mood and anxiety disorders in IBS. 

Treating both anxiety and IBS at the same time can help to break the unhealthy cycle where each condition causes the worsening of the other. Therefore, if you have IBS and experience anxiety and other psychological symptoms, you should see a mental health professional for psychological treatment. 

In addition to treatment for IBS symptoms, psychological therapies such as CBT and other stress management techniques may help to relieve symptoms of both IBS and anxiety.