By Erik Peper, PhD

Irritable bowel syndrome (IBS) is a common disorder affecting up to 15 percent of the adult population in the United States.¹ The chronic symptoms (ie, lasting longer than 30 days) usually include abdominal cramping, discomfort or pain, bloating, loose and/or frequent stools, and constipation, which can significantly reduce quality of life.

A precursor of IBS in children is called recurrent abdominal pain (RAP), which affects 0.3 to 19 percent of school-aged children.² Both IBS and RAP appear to be functional illnesses as no organic causes have yet been identified to explain the etiology of symptoms. 

Multiple factors may contribute to IBS, such as genetics, food allergies, previous treatment with antibiotics, infections, psychological status, and stress. More recently, dietary factors contributing to changes in the intestinal and colonic microbiome resulting in small intestine bacterial overgrowth have been suggested as another risk factor.³

While treatment options are limited, complementary and alternative approaches such as biofeedback-assisted relaxation techniques, autogenic training, and cognitive therapy have been shown to be more effective than traditional medical treatment modalities.^{4 5 6}

Heart Rate Variability Training

Biofeedback-assisted relaxation training typically moderates IBS or RAP symptoms by restoring balance in the nervous system, such as through heart rate variability (HRV) breathing training. For example, two recent studies demonstrated that functional abdominal pain can be reduced with HRV feedback training.^{7 8}

In most cases, increased vagal tone was achieved by breathing at about six breaths per minute. In fact, a randomized controlled study found that various yogic breathing techniques (eg, Shashankasana and Surya Nadi Pranayama) decreased diarrhea-predominant irritable bowel syndrome symptoms significantly more than conventional treatment.⁹

Nervous system balance can be enhanced by increasing HRV (five to seven breaths per minute). For most people, HRV training means breathing at much slower rate. A benefit of slow abdominal breathing appears to be a self-control strategy that can reduce symptoms of IBS, RAP, and similar functional abdominal pain symptoms.

Perspectives on Abdominal Discomfort among Students

In a recent survey of 99 undergraduate students, 41 percent self-reported abdominal discomfort (25 percent irritable bowel or acid reflux), 86 percent self-reported anxiety, 70 percent neck and shoulder tension, and 48 percent headaches.

After practicing slower breathing (ie, abdominal breathing at a rate of about six breaths per minute), many students reported that their symptoms significantly decreased. Specifically, the students were instructed to focus on slower exhalation and allowing the air to flow in without effort as the abdominal wall expands.

Case Example

A 16-year-old high school junior suffered from abdomen discomfort for years. The symptoms mainly consisted of frequent constipation and discomfort from nausea. After having been diagnosed and examined by the gastroenterologist, no identifiable cause was found. Biofeedback was suggested as an alternative to medications for symptom reduction.

During the initial appointment, the evaluation focused on the link between the student’s tendency to be sensitive and her concern about what others think. When describing herself, the student discussed her perfectionistic tendencies using a scale from lackadaisical/undemanding to perfectionist (ie, concern over mistakes, doubts about actions, self-criticism, socially prescribed perfectionism, hypercriticism). Of note, the student sat slouched in the chair, which may imply powerlessness rather than empowerment, and a state of being ready to react and protect.

Working Hypotheses

The student was very sensitive and continuously reacted to external and internal signals while masking her reactions. These ongoing fight/flight responses may decrease intestinal peristalsis and abdominal blood flow, resulting in abdominal distress, nausea, and constipation. Specifically, the body reacts to the stimuli as signals of danger, and blood flow is shunted away from the abdomen into the large muscles to run and fight. 

The treatment session began with an exploration of how pressure on the abdomen could potentially contribute to nausea and abdominal distress. After reviewing how the diaphragm descends and how abdominal content in the stomach can be displaced (spread out) during inhalation, the student was instructed to change her posture by placing a small pillow behind her middle back so that she could sit tall. 

The tall posture resulted in a sense of empowerment not felt during slouching. The student observed that breathing was slightly easier, and she felt there was more space in her abdomen. Additionally, the discussion focused on the direct relationship between thoughts, feelings, and abdominal discomfort.

Biofeedback Monitoring for Assessment

Various sensors were used to measure the patient’s skin conductance, psychophysiology, respiration, and blood volume. After sensors were attached, the student sat comfortably while looking at the screen. Unexpectedly the clinician clapped his hands and made a loud noise to gauge the student’s reaction. The physiological response showed an increase in skin conductance, decrease in pulse amplitude, decrease in abdominal diameter, and increase in heart rate (as shown in Figure 1).

FIGURE 1. Physiological response to a loud noise (clap) (1) increased skin conductance, (2) decrease in pulse amplitude, (3) decrease in decreased abdominal circumference, and (4) increased heart rate and decreased heart rate variability.

The student was aware that she reacted to the clap; however, she was completely unaware how much her body responded. The computer screen display of her physiological reaction made the invisible visible. It provided the opportunity to discuss how the various body reactions that relate to heart rate, breathing, and skin conductance could contribute to experiences of abdominal discomfort.

Skin conductance did not return to baseline levels for more than 20 minutes. An elevated skin conductance level may suggest that the body’s reaction to the hand-clap noise triggered a defense reaction and maintained the increased sympathetic activity for an extended period of time. 

Having a sustained flight/fight reaction to external stimuli such as a hand clap would most likely affect digestive and peristalsis processes, contributing to symptoms found in IBS and RAP. Additionally, blood volume pulse amplitude decreased—indicating a decrease in blood flow through her hands, which would decrease hand temperature and again indicate a systemic sympathetic activation.

Finally, the student’s abdominal circumference decreased, which indicated that she tightened her abdominal muscles as a protective response to the hand clap. She was unaware of the abdominal muscles tightening, though she stated that she was aware that her breathing had changed. Notably, the abdominal muscle, which pulled the abdomen in, took almost two minutes to relax. The sustained muscle constriction around the abdomen increased pressure around the core organs, which may contribute to ongoing abdominal discomfort.

A fight-flight reaction includes body bracing (eg tightened muscles, head down to protect the neck, big bones of arms and legs curled to protect core organs), and the student confirmed that she experienced neck and shoulder tensions.

Building a Psychophysiological Model

Using these recorded computer images reflecting physical reactions to the hand clap and emotional thoughts, follow up evaluations focused on the role of emotional responses in abdominal discomfort. The student shared that she was very sensitive and reactive especially when other people were upset. She reported feeling “cursed” by sensitivity and reactivity. The linguistic metaphor that could be used to describe her reactions is “she could not stomach what was going on.”

The discussion about physiological reactions provided the client with a model how her disorder (IBS and RAP) could have developed and been maintained over the years. The model matched her subjective experience: when stressed, the discomfort often increased. The discussion shifted to reframing her internal labels. Instead of describing her sensitivity as a curse, the sensitivity was reframed and labeled a gift.

By reframing her symptoms as a result of a survival physiological response pattern, it reduces self-blame and offers solutions about how to master and change reactions and thereby have more control.

Training to Demonstrate Control

The discussion was followed by teaching the student diaphragmatic breathing in sitting and supine positions. As she had no history of abdominal injuries, she rapidly demonstrated slower diaphragmatic breathing as shown in Figures 2 and 3.

FIGURE 2. The client practiced a few slower diaphragmatic breaths in the sitting and reclining position, which increased heart rate variability, decreased skin conductance, and increased blood volume pulse amplitude.

FIGURE 3. Practicing slower diaphragmatic breathing at about six breaths per minute in a reclining position increased HRV.

With tactile coaching, the student demonstrated that she could breathe at about six breaths per minute with the heart rate increasing during inhalation and decreasing during exhalation. She reported feeling more relaxed and that the sensations of nausea had disappeared. Additionally, her hands felt warmer.

During the last part of the session, the clinician explained how breathing may affect heart rate variability. Namely, if she allowed exhalation to occur without effort, her heart rate can decrease (the vagal response of slowing the heart) and thereby increase the parasympathetic activation that would support digestion and gastrointestinal functioning.

Interestingly, when people practice effortless diaphragmatic breathing, abdominal noises (borborygmus)—the gurgling, rumbling, or squeaking noise from the abdomen—occur and indicate that intestinal activity is being activated, and that food, liquids, and digestive juices are moving through the intestines. It is usually a positive indicator that the individual is relaxing, and sympathetic activity has been reduced.

Recommendations for Future Sessions and Home Practice

Future sessions would focus on encouraging the student to practice slow diaphragmatic breathing for 10 to 20 minutes per day and incorporate imagery to boost performance (ie, air flowing down the arms and legs during exhalation). More importantly, with practice, the student may begin to generalize the skill in daily life. Namely, whenever she senses stress or observes herself holding her breath or breathing in her chest, she could use that as the cue to shift to slower abdominal breathing. ? 

Erik Peper, PhD is a professor at San Francisco State University. He is President of the Biofeedback Foundation of Europe and former president of the AAPB. He has a biofeedback practice at www.biofeedbackhealth.org and publishes the blog www.peperperspective.com. His most recent book is TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics.

Adapted by permission from Peper, E & Harvey, R (2022). “Nausea and GI Discomfort: A Biofeedback Assessment Model to Create a Rational for Training.” Biofeedback, 50(1), 24–32.  https://doi.org/10.5298/1081-5937-50.1.05

References

1. “Irritable Bowel Syndrome.” American College of Gastroenterology, March 21, 2022. https://gi.org/topics/irritable-bowel-syndrome/#:~:text=IBS%20is%20a%20very%20common,women%20having%20it%20than%20men.
2. Chitkara, Denesh K, et al. “The Epidemiology of Childhood Recurrent Abdominal Pain in Western Countries: A Systematic Review.” American Journal of Gastroenterology 100(8): 1868-1875, Aug 2005.
3. H L DuPont. “Review article: evidence for the role of gut microbiota in irritable bowel syndrome and its potential influence on therapeutic targets.” Alimentary Pharmacology and Therapeutics 39(10): 1033-1042, May 2014.
4. Joshua Z Goldenberg, et al. “Biofeedback for treatment of irritable bowel syndrome.” Goldenberg JZ, et al. “Biofeedback for treatment of irritable bowel syndrome.” Cochrane Database of Systematic Reviews 2019, Issue 11. Art. No: CD012530. DOI: 10.1002/14651858.CD012530.pub2.
5. Mark J Stern, et al. “HRV Biofeedback for Pediatric Irritable Bowel Syndrome and Functional AbdominaPain: A Clinical Replication Series.” Applied Psychophysiology and Biofeedback 39:287–291 (2014).
6. “Use of complementary and alternative medicine by pediatric patients with functional and organic gastrointestinal diseases: results from a multicenter survey.” Pediatrics. 2008 Aug;122(2):e446-51.
7. Erik Sowder, et al. “Restoration of Vagal Tone: A Possible Mechanism for Functional Abdominal Pain.” Applied Psychophysiology and Biofeedback 35:199–206 (2010).
8. X Sun, et al. “Short-term and long-term effect of diaphragm biofeedback training in gastroesophageal reflux disease: an open-label, pilot, randomized trial.” Diseases of the Esophagus 29(7):829–836 (Oct 2016).
9. Indu Taneja, et al. “Yogic Versus Conventional Treatment in Diarrhea-Predominant Irritable Bowel Syndrome: A Randomized Control Study.” Applied Psychophysiology and Biofeedback 29:19–33 (2004).