The brain-gut connection

Treatments usually prescribed for mental illness are now being used for physical pain


The brain-gut connection

In the coming year, a team of researchers from Canada and the U.S. will begin a study to determine the best way to treat the worst gut problems, including severe diarrhea, gas, bloating, nausea and “chronic constipation where you have excruciating cramps [that feel] like labour pain,” says Brenda Toner, a psychologist and co-head of social equity and health research at the Centre for Mental Health and Addiction, who is leading the investigation. But they won’t be looking at antacids, laxatives or enemas. The most effective remedies may be ones normally prescribed for mental illness: antidepressants or talk therapy, or both. “What I’ve been trying to do is put the mind and the body back together,” says Toner, who heads the women’s mental health department at the University of Toronto.

This surprising study is the latest research acknowledging the connection between anxiety or depression and gastrointestinal problems. “Most of us, when we’re under stress, respond with a GI symptom,” says Toner, up to 70 per cent of people, in fact. Think about how sick to your stomach you felt before that big meeting or when you were worried about someone you love. Gut discomfort is one of the biggest reasons people miss school or work, second only to the common cold. And for people whose pain is persistent, which is typical because many GI disorders are chronic, the psychological impact can be devastating. “The brain-gut interaction is a prominent one,” says Nicholas Diamant, a gastroenterologist and professor of medicine at the University of Toronto, who is working with Toner on the study. “There are a lot of things about gut symptoms that impact patients in a mental way,” he explains, which “will not only affect their mood but also their behaviours—whether they go to work or out to socialize.”

The physical pain is real and dogged. “On bad days it feels, literally, like somebody has taken a knife and stabbed it in my lower left side and is dragging it across my stomach,” says Jeffrey Roberts, 47, who has suffered from irritable bowel syndrome since he was a teenager. The symptoms fluctuate between diarrhea, constipation, nausea and cramps. Roberts, who lives in Toronto, is also lactose intolerant and was diagnosed with Crohn’s disease on his 40th birthday. The gut discomfort has forced him to reschedule a family trip to Disney World and cancel an Italian romantic getaway with his wife.

One of the most famous victim of eviscerating GI pain was Kurt Cobain, who hauntingly foreshadowed his own death when describing how gut symptoms sent him into a downward spiral: “It had been building up for so many years that I was suicidal. You know, waking up starving, forcing myself to eat, barfing it back up . . . just crying at times, ‘Urgh, I’m in pain all the time.’ ”

On top of the physical distress, Roberts says he and others like him suffer mental and emotional symptoms. (Cobain’s proof.) Anxiety and depression begin to creep in. “You worry that people see you as a hypochondriac,” he says, “as if it’s all in my head.” Some sufferers feel hopeless, which is a common reaction to chronic pain. Even the practical aspects of living with a major gut problem—always needing to know there’s a bathroom nearby, for example—can wear people down. ‘‘I don’t know anything that is more distressing for a patient,” says Diamant, a senior scientist at Toronto Western Research Institute, “than to fill their pants full of poop at the grocery store.”

The body, of course, reacts to stress in all kinds of ways. The cardiac system may respond with a hastened heartbeat; the vascular and nervous systems may cause a migraine headache. “But the gut seems to be the one [system] that’s more sensitive,” says William Paterson, a neurogastroenterologist and research chair at Queen’s University in Kingston, Ont. The gut includes everything from the salivary glands, the pharynx and esophagus to the stomach, intestines and anus, plus organs like the liver and pancreas. It’s huge and complex. “There are more nerves in the wall of the gut than there are in the spinal cord,” says Paterson, past president of the Canadian Association of Gastroenterology. It’s so responsive that scientists often refer to the gut as the “little” or “second” brain.

One of the big questions in medical circles is what comes first: the anxiety and depression or the GI problems? At this point, it’s hard to say. “It’s chicken or the egg,” says Paterson, but he believes there’s overwhelming evidence that mental illness doesn’t cause gut disorders such as IBS, which afflicts up to 20 per cent of the Canadian population. “But if you have anxiety and depression, you’re more likely to have or be concerned about IBS symptoms,” he says. “And if you have severe IBS symptoms, it’ll affect your mental health.” Experts point out that IBS symptoms can have no negative impact on a person’s mental health, especially if they’re minor or moderate. “So some people have mild IBS and can cope,” says Toner.

A 2006 study published in the Archives of Internal Medicine showed that people with mental disorders have double the chance of having a digestive illness; 20 per cent of patients suffering from a GI disorder have anxiety, compared to eight per cent of people with a healthy gut. One of the study’s authors, Jitender Sareen, thinks the relationship is bidirectional. “The anxiety leads to more GI problems, the GI problems lead to more anxiety,” says the University of Manitoba psychiatry professor. “It becomes a kind of cycle.”

Science is slowly figuring out more about the relationship between the big and little brains. In people who experience serious IBS symptoms, some neuro-pathways may not work properly—the sensory signal may not be regulated properly, let’s say, and pain is the result. Other research, looking at how activity is transmitted from the gut to the brain, is focusing on a hormone called corticotropin-releasing factor or CRF, which Paterson says is increasingly thought to trigger abnormal gut activity during stressful situations.

High stress levels combined with a bacterial stomach infection (gastroenteritis)—say from salmonella, E. coli or C. difficile, the latter two of which plagued parts of Canada recently (remember the contaminated Harvey’s in North Bay and the hospital in Regina?)—also make people more susceptible to developing IBS, showed a 2007 New Zealand study published in Gut. In Walkerton, Ont., which experienced Canada’s worst E. coli water contamination ever, 27.5 per cent of people who reported suffering gastroenteritis got IBS.

The relationship between the mind and gut is particularly relevant—and complicated—when talking about IBS because it’s one of many “functional” disorders, just like acid reflux, chronic constipation or dyspepsia, which is characterized by persistent burning stomach pain, bloating, burping, heartburn, nausea and even vomiting. With these conditions, tests including blood work or colonoscopies often can’t detect any “organic or biochemical” abnormalities in patients, says Toner. The pain is real, but “we can’t say, ‘There’s a lesion and it’s this big and that explains the pain.’ ” Sometimes patients are told, wrongly, that there’s nothing wrong with them.

That contributes to the shame and stigma associated with gut problems. Those are evident on the IBS website Roberts has run since 1989, www.ibsgroup.org, which offers support and information. Although the site has 30,000 registered visitors, every month up to 200,000 unique visitors “are lurking behind the scenes because they don’t know if they have [IBS], or they don’t want their employer or spouse to know.” Gas and diarrhea aren’t considered socially appropriate talking points, says Toner, especially when it comes to females. Unfortunately, in North America women constitute between 70 and 90 per cent of IBS patients. No one knows for sure why women are diagnosed more, but a popular theory says it’s because Canadian and American women seek medical attention more often than men.

All this makes for a perfect storm that has medical professionals and scientists scrambling to find a fix. That’s where Toner’s research looking at antidepressants and a type of talk therapy called cognitive behavioural therapy (CBT) comes in. A few years ago, she and colleagues discovered that CBT was more effective in helping patients cope with moderate to severe gut problems than no talk therapy at all. CBT sees the patient work with a psychologist to identify triggers that set off the worst symptoms. Patients talk about what’s going through their mind when they are in the throes of pain or feeling overcome by anticipatory anxiety and figure out techniques to reduce symptoms such as relaxation exercises. “It’s not magical or mysterious,” says Toner. “It’s practical, and that’s why people like it.”

Toner’s research also found that a low, regular dose of the antidepressant desipramine was more helpful than a placebo pill. Now, her team is recruiting 200 women with IBS to participate in another study to determine which of the two treatments is best, or to find out if the ideal remedy would be to administer both to patients.

Diamant says that the antidepressants prescribed for pain management are usually at doses much lower than would be required to treat mental illness—a 10th or a 20th the dose sometimes. The drugs work because they affect the neuro-pathways that send and receive signals between the brain and gut. Many antidepressants have “anticholinergic” properties, which means they can alleviate diarrhea and cramps.

Roberts has benefited from both CBT and antidepressants. But he is all too aware that these treatments come with a lot of baggage. When his doctor recommended he try them, he was indignant. “I had the same reaction as a lot of people: why am I taking this? I’m not crazy.” But as he understood how the remedies worked—and when his symptoms got worse—he came around to the idea. Today he talks to people about the promise of these surprising treatments. “It really does work,” he says. “The people I worry about are the ones who are not getting treatment and are suffering needlessly.”

All this reminds Toner of a similar situation facing doctors and patients years ago, when everyone thought ulcers were caused solely by stress. Then, in a stunning discovery, researchers identified a bacteria, Helicobacter pylori, that was the culprit behind so much physical and psychological devastation. “I think that is a lesson,” she says, in particular when talking about functional disorders such as IBS, “that we’re still figuring [it] out.” Months or years from now, says Paterson, we may find out that if you really look with more sophisticated techniques there’s abnormal accumulation of certain inflammatory cells in the lining of the bowel, for example. “But just like with any other illness,” says Toner, “worry, anxiety, depressive symptoms and stress are associated.”


The brain-gut connection

  1. We have published a groundbreaking book, Migraine Expressions, depicting
    the world of life with migraine through the art and words of the most precious and trusted sources – those who live in it.
    The poetry, essays, art and photography in this book illuminate the hope, optimism, and accomplishments in our lives as well as the painful, dark and lonely times.
    As a platform for migraineurs and their loved ones to share experiences, this book also inherently promotes awareness and a real understanding of migraine and exposes the urgent need for more education, research, and effective treatments.

    Betsy Blondin, Editor, Word Metro Press

    P.S. Here are some quotes from leaders in the field:
    “The images and the words are compelling. Migraineurs will relate to the visual images and the poems. Those who don’t suffer may be better able to empathize after reading the book.”
    Suzanne E. Simons – Executive Director
    National Headache Foundation
    “Migraine Expressions reveals a neurobiological disease from many highly
    personal perspectives as contributors transform their experiences into
    stunning verbal and visual art. The book will help people with migraine
    find their individual voices even as they recognize the universality of
    their shared experiences.”
    Richard B. Lipton, MD – Professor of Neurology
    and Director, Montefiore Headache Center
    Albert Einstein College of Medicine
    “Projects such as Migraine Expressions are rare, priceless, and sorely needed. They offer an intimate view of the impact of Migraine disease. The works of art in this book are deeply personal and revealing. They are heart-wrenching and inspiring, filled with both terror and hope.”
    Teri Robert, Ph.D. – Writer, educator, and patient advocate
    Author of Living Well with Migraine Disease and Headaches
    This collection of personal expressions from people around the world impacted by this disease illustrates some of the ways millions upon millions of migraineurs and their loved ones feel, love, work and play while trying to manage symptoms and live as well as possible.

  2. I have had Crohn’s all of my adult life (diagnosed for 16 yrs.) and have had 2 bowel resections. I also have Crohn’s related inflammatory arthritis (all the pain of Rheumatoid, but no joint degeneration) and high blood pressure. I suffer from overwhelming fatigue and pain ALL THE TIME. And now in my late 40’s I am dealing with “women” problems.

    My chief frustration is my inability to get any of my many, many doctors to treat pain effectively. I’m stuck in a horrible conundrum, where each doctor treats just a symptom related to their specialty but no one treats me as a whole entire person. Its like the story about the blindfolded men each touching one part of the elephant and trying to determine what kind of animal they are dealing with.

    My family doctor, who is wonderful is hampered in that she must defer to the specialists; the specialists deal only with their specialty and focus on solving the larger problem always looking for new treatments, however in the last year for instance I have become even more depressed (always an issue in my situation) and housebound. I am not coping and it is affecting my whole family, especially my youngest child, a 17 yr. old who suffers from IBS.

    Yet even though my symptoms are worse I am still on the same pain regimen I have been on for years. My doctors worry about addiction and their reputations, which I respect, yet all the studies they’ve discussed with me, and that I have read myself bear out the fact that the minds of people in pain do not behave the same way as those of addicts. I myself have never felt the sensation of being “high” from pain meds. I don’t drink nor do I smoke pot, although many family members and friends push me to. What they don’t understand is that pot would make me stoned and vegetative (I have tried it) whereas I want something to take the pain away so I can function at my day to day tasks. And I know there are millions like me.

    • …… I’m spooling down on my anti-deps [citalopram ‘celixa’,…you know the one ,’they’ have found to cause sudden heart attacks in some individuals] . Further, the panic- anxiety drug ‘Clonazepam’,.. I keep it on standby when I need it but generally just use it on occasion when my mind won’t ‘shut off ‘ at bedtime.
      My saving grace has proven to be…..pot, in moderation [ one toke in the morning, lasts for about four to six hours, and thats only when I get ‘uptight and outa sight,’ not every day! ] it truly makes a difference in how I view the world around me [calm and light-hearted]
      My wife knows when its ‘time for a toke’ for daddy and we both notice the difference, in minutes!
      Its time we shot the messenger [media], I don’t have TV or radio. Watch what you put in your mouth.
      Google ‘Inositol’, Vitamin B8,…give that a go. The mind body connection, I’m only starting to pay attention to it now at sixty-two. Your son needs to take responsibility, for himself with a good diet, exercise and good friends [ You have your plate full ] or he’s going to be wearing a bag before he’s twenty…totally unnecessary. My gawd what we have come to as a species. You have my heart-felt sympathy. Like you say, ‘many more out there’ reacting to the stresses of our times….

  3. Almost thirty years ago I spent three years in a university-approved research project, interviewing individuals concerning the history of illness and social experiences. They had all been diagnosed and treated for inflammatory bowel disease (IBD) – either ulcerative colitis or Crohn’s disease. The interviewees were guaranteed anonymity and agreed that I had no therapeutic advice to give them. Within that group of over 40 people, there were five who claimed to have found that their illness had gone into complete remission. The remedy they had all found was to separate themselves from an abusive relationship – not always physical abuse, but emotional blackmail in which they claimed to have been receiving from an authoritarian (and in two cases, mentally ill partners) These individuals were not known to each other. Their narratives were unprompted, but almost identical. They had not revealed this outcome to their medical advisors. They claimed that this insight into their stress had occurred to them as a revelation, a kind of psychological ‘conversion’. All the other interviewees offered biographies that contained periods of extreme guilt, fear and anger and a sense of helplessness in dealing with highly ambiguous relationships. One case will illustrate this. A young woman had been raped by the brother of her fiancee on the night of her engagement. Shortly afterwards her symptoms began.Her fear of reprisal had prompted her to keep the abuse a secret. She had offered her gastroenterologist the suggestion that anxiety may play a role in her colitis, but he had dismissed this out of hand and recommended a prophylactic panproctocolectomy which was scheduled for the following week. The stigma of bowel disorders is compounded by the sense of shame associated with incompetence in dealing with highly ambiguous relationships. Individuals who have received colostomies or ostomies reflect spontaneously on the fact that their spouse or parent had been ‘the source of their aggravation and fear’ and regretted the fact that they had not sought counselling for these matters. I am fully aware of the recognition that sees IBS as a stress-based pathology. But IBD has not received the same kind of acknowledgement with respect to etiology. Veterinary science accepts that IBD in animals is a stress-based disorder and treats the condition accordingly and with success. I believe that it is absolutely vital for anyone suffering from IBD to seek counselling, from a clinical psychologist with expertise in cognitive behaviour therapy. There are clearly ancillary factors that predispose to IBD but emotional stress is the most important, in that it hijacks the auto-immune system. Despair caused by suffering is always present. But for most people, it is the sense of helplessness in coping with abuse that is identified as the trigger for their pathology. Gastroenterologists do their best to manage symptoms through medication and surgery. But they remain highly sceptical in viewing IBD as a biopsychosocial condition, although psychoneuroimmunology is proceeding in this direction. The message given to patients is that they are suffering from an incurable condition. This deprivation of hope (and the nocebo effect it has) dissuades patients who might possibly find remission from seeking alternative opinions. In recent years, apart from my original research, I had encountered 20 other post-IBD sufferers who have experienced remission by taking steps to alleviate the stress in their lives.

    • Good to hear. Keep up the good work.
      Your erstwhile friend
      Terry still at same address.

    • This was very valuable. thank you. please list peer reviewed journal articles for further reading. thanks.

  4. I have a crippling form of arthritis as well as severe Legg Calve Perthes Disease, and I have been on Lorazepam and other anti-anxiety meds for years, because when I go through extreme pain (7+) my muscles tighten and contract, and the pain gets worse.
    Taking the pills allows my muscles to relax and me to breathe normally.

  5. My wife was declared as having met with ‘brain death criteria’, within only a few hours following her transfer from Kirkland Lake to Sudbury, while under the care of Drs. Sauve and Adegbite. Withholding life sustaining treatment from an “undiagnosed” patient with concurrent hyperglycemia, hypokalemia and electrolyte abnormalities in combination with a severely paralysed motor function and who is under the influence of sedative hypnotic and tranquilizing agents is of questionable legality. For the record, many conditions may falsely mimic brainstem death clinically upon examination, but without excluding them you will KILL a person by homicide, or criminal negligence, despite the reversibility of brain damage.


  6. The truehope company, the equilib company and the quiet minds company online all sell supplements that fix the absorption problem to reverse the mental illness symptoms. There is also a company online that really works to maximize absorption called ENZYMEDICa – digest spectrum. I took it for schizophrenia bipolar type combined with a huge amount of vitamins/minerals, and amino acids from the truehope company online and my symptoms of mental illness are now gone.
    It is an absorption issue. It is not a problem with the brain. Big pharma wants to keep you ignorant and sick.

  7. This is why the truehope company online works and other companies that sell supplements for mental illness in huge dosages. Mental illness is really malnutrition. There is nothing wrong with the brain and that is why treating mental illness with tranquilizers and adding chemicals to the brain is not fixing the root cause. First we have to stabilize people with a lot of nutrients and if possible they have to find a way to cure the digestive system. IF they cannot find a way to cure the digestive system, then they should be supplementing heavily to make sure people’s brains are not starving for nutrients which is causing the mental illness in the first place.

  8. The part of the article asks what comes first, the depression and anxiety or the ibs symptoms? Well this article originally talked about how antidepressants are being used for ibs showing a link between ibs and depression. When I was 12 that was when I began suffering from both ibs and depression. So really it’s likely that it’s all about the lack of serotonin in the brain AND gut. So neither is first, depression & ibs happens together, and then the anxiety comes later on because of the fear of being sick when you’re out somewhere. I didn’t start having anxiety problems until I actually started needing to go to the bathroom all the time! My ibs originally started with just pain and became severe when I was in 12th grade which is then caused anxiety and it screwed up my social life.

Sign in to comment.