Jump to ContentJump to Main Navigation
Show Summary Details
More options …

Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald

CiteScore 2017: 0.84

SCImago Journal Rank (SJR) 2017: 0.401
Source Normalized Impact per Paper (SNIP) 2017: 0.452

See all formats and pricing
More options …
Volume 18, Issue 1


Cognitive behavioral therapy for irritable bowel syndrome: the effects on state and trait anxiety and the autonomic nervous system during induced rectal distensions – An uncontrolled trial

Hanna Edebol-Carlman
  • Corresponding author
  • Nutrition-Gut-Brain Interactions Research Centre, Örebro University, Örebro 701 82, Sweden, Phone: +46 (0) 19 30 33 22, Mobile: +46 (0) 732 707 624
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Martien Schrooten
  • Center for Health and Medical Psychology (CHAMP), School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Brjánn Ljótsson
  • Department of Clinical Neuroscience, Division of Psychology and Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Katja Boersma
  • Center for Health and Medical Psychology (CHAMP), School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Steven Linton
  • Center for Health and Medical Psychology (CHAMP), School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Robert Jan Brummer
Published Online: 2018-03-06 | DOI: https://doi.org/10.1515/sjpain-2017-0153


Background and aims:

Irritable bowel syndrome (IBS), is a common multifactorial gastrointestinal disorder linked to disturbances in the microbe gut-brain axis. Cognitive behavioral therapy (CBT), in face-to-face format has showed promising results on IBS and its associated psychological symptoms. The present study explored for the first time if CBT for IBS affects the autonomic nervous system (ANS) during experimentally induced visceral pain and cognitive stress, respectively. The levels of state and trait anxiety, current and perceived stress were also evaluated.


In this uncontrolled trial, individual CBT was performed in face-to-face format for 12 weeks in 18 subjects with IBS. Heart rate variability and skin conductance were measured during experimentally induced visceral pain and during a cognitive task (Stroop color-word test), before and after intervention. The levels of state and trait anxiety as well as self-rated current and perceived stress were also measured before and after the intervention.


CBT did not affect ANS activity during experimentally induced visceral pain and cognitive stress. The sympathetic activity was high, typical for IBS and triggered during both visceral pain and cognitive stress. The levels of state and trait anxiety significantly decreased after the intervention. No significant changes in self-rated current or perceived stress were found.


Results suggest that face-to-face CBT for IBS improved anxiety- a key psychological mechanism for the IBS pathophysiology, rather than the autonomic stress response to experimentally induced visceral pain and cognitive stress, respectively.


This study indicates that IBS patients present high levels of stress and difficulties coping with anxiety and ANS activity during visceral pain and a cognitive stress test, respectively. These manifestations of IBS are however not targeted by CBT, and do not seem to be central for the study participants IBS symptoms according to the current and our previous study. Face-to-face CBT for IBS, it does not seem to affect modulation of ANS activity in response to induced visceral pain or cognitive stress. Instead, face-to-face CBT decreased levels of state and trait anxiety. Implications for further studies include that anxiety seems to be important in the IBS pathophysiology, and needs further scientific attention. This is in line with the fear-avoidance model which suggests that anxious responses to pain and discomfort drive hypervigilance to, and (behavioral) avoidance of, symptom provoking stimuli and vice versa. Catastrophic cognitions, hypervigilance and avoidant behavioral responses are proposed to produce vicious circles that withhold and exacerbate pain-related symptoms and disability, and lead to lower quality of life. Larger scale studies of potential autonomic changes are needed in order to elucidate which mechanisms elicit its effects in face-to-face CBT for IBS, and provide new avenues in understanding the pathophysiology of IBS.

Keywords: irritable bowel syndrome; cognitive behavioral therapy; state anxiety; trait anxiety; stress; autonomic nervous system; visceral hypersensitivity


  • [1]

    Quigley EM, Abdel-Hamid H, Barbara G, Bhatia SJ, Boeckxstaens GE, DeGiorgio R, Delvaux M, DiBaise J, Drossman DA, Foxx-Orenstein BA, Guarner F, Gwee KA, Harris L, Hungin P, Hunt R, Kellow J, Khalif I, Kruis W, Lindberg G, Olano C, et al. A global perspective on irritable bowel syndrome. A consensus statement of the World Gastroenterology Organization (WGO) summit task force on irritable bowel syndrome. J Clin Gastroenterol 2012;46: 356–66.CrossrefGoogle Scholar

  • [2]

    Van Der Veek PPJ, Dusseldorp E, Van Rood YR, Masclee AAM. Testing a biobehavioral model of irritable bowel syndrome. Eur J Gastroenterol Hepatol 2010;22:412–9.PubMedWeb of ScienceCrossrefGoogle Scholar

  • [3]

    König J, Ganda Mall JP, Rangel I, Edebol-Carlman H, Brummer RJ. The role of the gut microbiota in brain function. In: Venema A, Paula do Carmo A, editors. Probiotics and Prebiotics: Current Research and Future Trends. Norfolk, UK: Caister Academic Press, 2014. ISBN: 978-1-910190-09–8.Google Scholar

  • [4]

    Hungin PS, Becher A, Cayley B, Heidelbaugh JJ, Muris JWM, Rubin G, Seifert B, Russell A, De Wit NJ. Irritable bowel syndrome: an integrated explanatory model for clinical practice. Neurogastroenterol Motil 2015;27:750–63.CrossrefWeb of SciencePubMedGoogle Scholar

  • [5]

    Kilkens TOC, Honig A, van Nieuwenhoven MA, Riedel WJ, Brummer RJM. Acute tryptophan depletion affects brain-gut responses in irritable bowel syndrome patients and controls. Gut 2004;53:1794–800.PubMedCrossrefGoogle Scholar

  • [6]

    Kilkens TOC, Honig A, Fekkes D, Brummer RJM. The effects of an acute serotonergic challenge on brain-gut responses in irritable bowel syndrome patients and controls. Aliment Pharmacol Ther 2005;22:865–74.CrossrefPubMedGoogle Scholar

  • [7]

    Labus JS, Mayer EA, Jarcho J, Kilpatrick LA, Kilkens TOC, Evers EAT, Backes WH, Brummer RJM, Van Nieuwenhoven MA. Acute tryptophan depletion alters the effective connectivity of emotional arousal circuitry during visceral stimuli in healthy women. Gut 2011;60:1196–203.CrossrefPubMedWeb of ScienceGoogle Scholar

  • [8]

    Cheng P, Shih W, Alberto M, Presson AP, Licudine A, Mayer EA, Naliboff BD, Chang L. Autonomic response to a visceral stressor is dysregulated in irritable bowel syndrome and correlates with duration of disease. Neurogastroenterol Motil 2013;25:e650–9.Web of SciencePubMedGoogle Scholar

  • [9]

    Mazurak N, Seredyuk N, Sauer H, Teufel M, Enck P. Heart rate variability in the irritable bowel syndrome: a review of the literature. Neurogastroenterol Motil 2012;24:206–16.Web of SciencePubMedCrossrefGoogle Scholar

  • [10]

    Salvioli B, Pellegatta G, Malacarne M, Pace F, Malesci A, Pagani M, Lucini D. Autonomic nervous system dysregulation in irritable bowel syndrome. Neurogastroenterol Motil 2015;27:423–30.PubMedCrossrefWeb of ScienceGoogle Scholar

  • [11]

    Boersma K, Ljotsson B, Edebol-Carlman H, Schrooten M, Linton SJ, Brummer RJ. Exposure-based cognitive behavioral therapy for irritable bowel syndrome. A single-case experimental design across 13 subjects. Cogn Behav Ther 2016;45: 415–30.Web of SciencePubMedCrossrefGoogle Scholar

  • [12]

    Ljotsson B, Falk L, Vesterlund AW, Hedman E, Lindfors P, Ruck C, Hursti T, Andreewitch S, Jansson L, Lindefors N, Andersson G. Internet-delivered exposure mindfulness based therapy for irritable bowel syndrome – a randomized controlled trial. Behav Res Ther 2010;48:531–9.CrossrefPubMedWeb of ScienceGoogle Scholar

  • [13]

    Ljotsson B, Andreewitch S, Hedman E, Ruck C, Andersson G, Lindefors N. Exposure mindfulness based therapy for irritable bowel syndrome – an open pilot study. J Behav Ther Exp Psychiatry 2010;41:185–90.Web of SciencePubMedCrossrefGoogle Scholar

  • [14]

    Ljotsson B, Andersson G, Andersson E, Hedman E, Lindfors P, Andreewitch S, Ruck C, Lindefors N. Acceptability, effectiveness, and cost-effectiveness of internet-based exposure treatment for irritable bowel syndrome in a clinical sample: a randomized controlled trial. BMC Gastroenterol 2011;11:110.CrossrefWeb of ScienceGoogle Scholar

  • [15]

    Ljotsson B, Hedman E, Andersson E, Hesser H, Lindfors P, Hursti T, Rydh S, Ruck C, Lindefors N, Andersson G. Internet-delivered exposure-based treatment vs. stress management for irritable bowel syndrome: a randomized trial. Am J Gastroenterol 2011;106:1481–91.CrossrefPubMedWeb of ScienceGoogle Scholar

  • [16]

    Ljotsson B, Hedman E, Lindfors P, Hursti T, Lindefors N, Andersson G, Ruck C. Long-term follow-up of internet-delivered exposure mindfulness based treatment for irritable bowel syndrome. Behav Res Ther 2011;49:58–61.CrossrefWeb of SciencePubMedGoogle Scholar

  • [17]

    Ljotsson B, Hesser H, Andersson E, Lindfors P, Hursti T, Ruck C, Lindefors N, Andersson G, Hedman E. Mechanisms of change in an exposure-based treatment for irritable bowel syndrome. J Consult Clin Psychol 2013;81:1113–26.CrossrefWeb of ScienceGoogle Scholar

  • [18]

    Ljotsson B, Hesser H, Andersson E, Lackner JM, El Alaoui S, Falk L, Aspvall K, Fransson J, Hammarlund K, Lofstrom A, Nowinski S, Lindfors P, Hedman E. Provoking symptoms to relieve symptoms: a randomized controlled dismantling study of exposure therapy in irritable bowel syndrome. Behav Res Ther 2014;55:27–39.PubMedWeb of ScienceCrossrefGoogle Scholar

  • [19]

    Andersson G, Cuijpers P, Carlbring P, Riper H, Hedman E. Guided Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis. World Psychiatry 2014;13:288–95.PubMedWeb of ScienceCrossrefGoogle Scholar

  • [20]

    Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology 2006;130:1480–91.PubMedCrossrefGoogle Scholar

  • [21]

    Svanborg P, Asberg M. A new self-rating scale for depression and anxiety states based on the comprehensive psychopathological rating scale. Acta Psychiatr Scand 1994;89:21–8.CrossrefPubMedGoogle Scholar

  • [22]

    Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction 1993;88:791–804.PubMedCrossrefGoogle Scholar

  • [23]

    Vanhoutvin SALW, Troost FJ, Kilkens TOC, Lindsey PJ, Jonkers DMEA, Venema K, Masclee A, Brummer RJM. Alternative procedure to shorten rectal barostat procedure for the assessment of rectal compliance and visceral perception: a feasibility study. J Gastroenterol 2012;47:896–903.Web of SciencePubMedCrossrefGoogle Scholar

  • [24]

    Pan J, Tompkins WJ. A real-time QRS detection algorithm. IEEE Trans Biomed Eng 1985;32:230–6.PubMedGoogle Scholar

  • [25]

    Dawson M, Schell A, Filion D. The electrodermal system. In: Cacioppo J, Tassinary L, editors. Handbook of Psychophysiology. Cambridge: Cambridge University Press, 2000:200–23.Google Scholar

  • [26]

    Stroop JR. Studies of interference in serial verbal reactions. J Exp Psychol 1935;18:643–62.CrossrefGoogle Scholar

  • [27]

    MacLeod CM. Half a century of research on the Stroop effect: an integrative review. Psychol Bull 1991;109:163–203.PubMedCrossrefGoogle Scholar

  • [28]

    Spielberger CD, Gorsuch RL, Lushene PR, Vagg PR, Jacobs AG. Manual for the state-trait anxiety inventory (Form Y). Palo Alto: Consulting Psychologists Press, Inc., 1983.Google Scholar

  • [29]

    Gros DF, Antony MM, Simms LJ, McCabe RE. Psychometric properties of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA): comparison to the state-trait anxiety inventory (STAI). Psychol Assess 2007;19:369–81.PubMedCrossrefGoogle Scholar

  • [30]

    Armelius BÅ, Bihlar B, Fahlke C, Fridell M, Katz Hillarp L, Reitan T. Bedömningsinstrument inom behandling och forskning för missbruks-och beroendevård. Statens institutionsstyrelse, SiS. 2010. [Instrument for assessment of treatment and research in addiction care. Governmental insitution board].Google Scholar

  • [31]

    Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:386–96.Google Scholar

  • [32]

    Naliboff BD, Benton D, Solomon GF, Morley JE, Fahey JL, Bloom ET, Makinodan T, Gilmore SL. Immunological changes in young and old adults during brief laboratory stress. Psychosom Med 1991;53:121–32.CrossrefGoogle Scholar

  • [33]

    Riedel WJ, Klaassen T, Deutz NE, van Someren A, van Praag HM. Tryptophan depletion in normal volunteers produces selective impairment in memory consolidation. Psychopharmacology (Berl) 1999;141:362–9.CrossrefPubMedGoogle Scholar

  • [34]

    World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013;310:2191–4.PubMedWeb of ScienceGoogle Scholar

  • [35]

    Mayer EA, Naliboff BD, Chang L, Coutinho SVV. Stress and irritable bowel syndrome. Am J Physiol Gastrointest Liver Physiol 2001;280:G519–24.PubMedCrossrefGoogle Scholar

  • [36]

    Edebol-Carlman H, Ljotsson B, Linton SJ, Boersma K, Schrooten M, Repsilber D, Brummer RJ. Face-to-face cognitive behavioral therapy for irritable bowel syndrome improves gastrointestinal and psychiatric symptoms via top-down coping rather than increased tolerance of bottom-up visceral-afferent signaling during rectal pain. Gastroenterol Res Pract 2017;2017:Article ID 8915872.Google Scholar

  • [37]

    Leeuw M, Goossens MEJB, Linton SJ, Crombez G, Boersma K, Vlaeyen JWS. The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence. J Behav Med 2007;30:77–94.PubMedCrossrefGoogle Scholar

  • [38]

    Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85:317–32.CrossrefPubMedGoogle Scholar

  • [39]

    Pletikosić Tončić S, Tkalčić M. A measure of suffering in relation to anxiety and quality of life in IBS patients: preliminary results. Biomed Res Intl 2017;2017:Article ID 238768.Google Scholar

  • [40]

    Schrooten M, Peters M, Vlaeyen JWS. Pain-related fear is a better predictor of disability than is pain intensity, also in chronic abdominal pain. Eur J Pain 2009;13:S55–285.Google Scholar

  • [41]

    Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39:175–91.PubMedCrossrefGoogle Scholar

About the article

Received: 2017-10-19

Revised: 2018-01-08

Accepted: 2018-01-10

Published Online: 2018-03-06

Published in Print: 2018-01-26

Authors’ statements

Research funding: None declared.

Conflict of interest: The authors declare that they have no conflicts of interest.

Informed consent: Informed consent was obtained from all participants included in the study.

Ethical approval: The study was approved by the regional ethical board, Etikprövningsnämnden, (www.epn.se) in Uppsala (number of the application: 2013/275) and conducted according to good clinical practice and the ethics of the Helsinki declaration.

Citation Information: Scandinavian Journal of Pain, Volume 18, Issue 1, Pages 81–91, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1515/sjpain-2017-0153.

Export Citation

©2018 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved..Get Permission

Citing Articles

Here you can find all Crossref-listed publications in which this article is cited. If you would like to receive automatic email messages as soon as this article is cited in other publications, simply activate the “Citation Alert” on the top of this page.

A.I. Melehin and J.S. Ignatenko
Journal of Modern Foreign Psychology, 2018, Volume 7, Number 4, Page 56

Comments (0)

Please log in or register to comment.
Log in