The role of avoidance behavior in the treatment of adolescents with irritable bowel syndrome: a mediation analysis
Open accessAbstract
Irritable bowel syndrome (IBS) is common in adolescents with a pronounced negative impact on quality of life. A pattern of avoidance behavior is commonly seen in the IBS population, which is associated with more gastrointestinal (GI) symptoms. Exposure-based cognitive behavior therapy (CBT) targets the avoidance behavior to reduce symptoms, but it is unknown whether reduced avoidance is a mediator of symptom improvement in adolescent IBS. Stress has been suggested to play a key role in worsening GI symptoms and is also a potential mediator of the treatment effect in IBS. This study was based on data from a randomized controlled trial (N = 101) that evaluated exposure-based internet-delivered CBT (Internet-CBT) compared with a wait-list for adolescents with IBS. We investigated whether avoidance behavior and perceived stress mediated the improvement in global GI symptoms due to treatment. We found that a change in avoidance behavior, but not perceived stress, mediated the effect of exposure-based Internet-CBT on GI symptoms. The decrease in avoidance behavior explained a large portion (67%) of the total treatment effect. Moreover, a unidirectional relationship over time was observed between avoidance behavior and GI symptoms. Our conclusion is that exposure-based CBT in adolescent IBS reduces avoidance and, consequently, reduces GI symptoms.
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Reduced avoidance behavior is a mediator in exposure-based CBT for pain.
“Reduced avoidance behavior is a mediator in exposure-based CBT for pain (Bonnert et al., 2018; Hedman-Lagerlöf et al., 2019).”
From Targeting excessive avoidance behavior to reduce anxiety related to asthma: A feasibility study of an exposure-based treatment delivered online (2021) · cites this paper as Bonnert et al., 2018
The Conclusions (section 5; page unavailable) report that reduced IBS-specific avoidance mediated improvement in GI symptoms during exposure-based Internet-CBT for adolescents with IBS. That supports the proposed mediation mechanism, but the cited study does not establish it for pain generally or for pain as a distinct outcome. (LLM, conf=0.88)
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“…avoidance is learned (e.g., Jepma et al., 2022; Meulders, 2019; Volders et al., 2015), how it influences different chronic conditions (e.g., (Bonnert et al., 2018; Hedman-Lagerl ¨ of et al., 2019; Knoop et al., 2010; Lenaert et al., 2018; Picon et al., 2021; Snell et al., 2023), and how it…”
Parental Factors in Pediatric Functional Abdominal Pain Disorders
Zeevenhooven, J., Rutten, J. M. T. M., Dijk, M. D. V.-V., Peeters, B., & Benninga, M. A. (2018) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1097/mpg.0000000000002163 · Cited by 15 · see citing works
Tanner, S. E., Murray, H., Brown, T. A., Malik, Z., & Parkman, H. (2023) · Neurogastroenterology and Motility · doi:10.1111/nmo.14534 · Cited by 15 · see citing works
Lalouni, M., Bujacz, A., Bonnert, M., Jensen, K. B., Rosengren, A., Hedman-Lagerlöf, E., Serlachius, E., Olén, O., & Ljótsson, B. (2022) · Frontiers in Pain Research · doi:10.3389/fpain.2022.962037 · Cited by 13 · see citing works
Self-citationZickgraf, H. F., & Schwartz, R. A. (2024) · Behaviour Research and Therapy · doi:10.1016/j.brat.2024.104677 · Cited by 10 · see citing works
Psychogastroenterology: A Cure, Band-Aid, or Prevention?
van Tilburg, M. A. L. (2020) · Children · doi:10.3390/children7090121 · Cited by 12 · see citing works
“Rather, it has been found that addressing gut-specific cognitions, emotions are the most effective part of psychological treatments for gut disorders [38,39].”
BackgroundLalouni, M., Olén, O., Bjureberg, J., Bonnert, M., Chalder, T., Hedman‐Lagerlöf, E., Rème, S. E., Serlachius, E., & Ljótsson, B. (2022) · Acta Paediatrica · doi:10.1111/apa.16403 · Cited by 10 · see citing works
Self-citationCognitive-behavioural therapy for children with irritable bowel syndrome
Buffone, A., & Goldman, R. D. (2021) · Canadian Family Physician · doi:10.46747/cfp.6712905 · Cited by 10 · see citing works
What are the mechanisms of psychological treatments for irritable bowel syndrome?
Ljótsson, B. (2019) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2019.01.003 · Cited by 9 · see citing works
Self-citationNielsen, E. S., Kallesøe, K. H., Gehrt, T. B., Bjerre-Nielsen, E., Lalouni, M., Frostholm, L., Bonnert, M., & Rask, C. U. (2024) · JMIR Research Protocols · doi:10.2196/58563 · Cited by 8 · see citing works
Self-citationKallesøe, K. H., Wellnitz, K. B., Ørnbøl, E., & Rask, C. U. (2023) · Children · doi:10.3390/children10071101 · Cited by 7 · see citing works
“, improvement of avoidance/limiting behavior [59,60], and catastrophic cognitions [61] in gastrointestinal FSD and pain-impairment beliefs in children with chronic pain [62].”
BackgroundEkholm, M., Krouwels, M., & Knittle, K. P. (2024) · Health Psychology and Behavioral Medicine · doi:10.1080/21642850.2024.2311986 · Cited by 7 · see citing works
“Avoidant coping strategies might thereby help the individual to stay in control in the short term, but avoidance behaviors can also act as a maintaining mechanism for IBS (Bonnert et al., 2018; Jones et al., 2006; Keefer et al., 2005).”
Leake, H. B., Moseley, G. L., Stanton, T. R., Heathcote, L. C., Pate, J. W., Wewege, M. A., & Lee, H. (2021) · Children · doi:10.3390/children8020147 · Cited by 7 · see citing works
“[32] Exposure-based internet-CBT vs waitlist + GI-specific avoidance behaviour + GI symptoms +”
BackgroundInfluentialYoga, Meditation, Mindfulness, or Hypnotherapy for GI Disorders: Similar Mechanisms of Action?
Hamal, A., Shin, A., & van Tilburg, M. A. L. (2025) · Neurogastroenterology & Motility · doi:10.1111/nmo.15014 · Cited by 5 · see citing works
Rezaei, N., Zahedi, S. T., Hajihashemi, P., Nasiri‐Dehsorkhi, H., Zamani, A., Ebrahimi, A., Adibi, P., & Armstrong, D. (2025) · Eating Disorders · doi:10.1080/10640266.2025.2519904 · Cited by 5 · see citing works
The Emerging Role of Brain-Gut Therapies for Irritable Bowel Syndrome.
Riehl, M. E. (2018) · Europe PMC (PubMed Central) · Cited by 4 · see citing works
Nabavi, M., Shahbazi, M., & Koraei, A. (2021) · The Journal Of Psychological Science · doi:10.52547/jps.20.106.1897 · Cited by 4 · see citing works
Milford, E. R., Buratti, S., Cunningham, N. R., Nilses, Å., Bratt, E., & Weineland, S. (2025) · JMIR Formative Research · doi:10.2196/67106 · Cited by 3 · see citing works
“Although the long-term effectiveness of broader multicomponent CBT, such as ADAPT, where several strategies are included as opposed to exposure-focused therapy, has been questioned [29].”
Exposure-based Interventions for Chronic Pain and Bodily Symptoms: A Special Interest Meeting Report
Schemer, L., Glogan, E., Sjouwerman, R., Ahm, R., Ashar, Y. K., Boddez, Y., Boersma, K., Cañeiro, J. P., Cima, R. F. F., den Hollander, M., et al. (2026) · Behaviour Research and Therapy · doi:10.1016/j.brat.2026.104998 · Cited by 3 · see citing works
“…of gut-brain interaction disorder in pediatric samples (Bonnert et al., 2017; Lalouni et al., 2019), with evidence suggesting that reductions in avoidance, symptom-related fear, and parental cata-strophizing (Bonnert et al., 2018; Lalouni et al., 2021, 2022) mediated improvements in gut symptoms.”
Self-citationSugaya, N., Tomita, Y., Funaba, M., Iida, H., Shirotsuki, K., Gardner, F. C., Odawara, T., Ando, T., & Inamori, M. (2022) · BioPsychoSocial Medicine · doi:10.1186/s13030-022-00244-3 · Cited by 3 · see citing works
“[17] reported that changes in IBS-related unhelpful behavior assessed by the IBS-BRQ [16] mediated the effect of exposure-based InternetCBT on gastro-intestinal (GI) symptoms.”
MethodSingh, H. S., Hulgaard, D. R., Nielsen, E. S., Kallesøe, K. H., Bonnert, M., Lalouni, M., & Rask, C. U. (2025) · Journal of Health Psychology · doi:10.1177/13591053251320600 · Cited by 3 · see citing works
“(Bonnert et al., 2018; Lalouni et al., 2021).”
Self-citationNielsen, E. S., Kallesøe, K. H., Lalouni, M., Carlsen, A. H., Frostholm, L., Bonnert, M., & Rask, C. U. (2025) · Journal of Pain · doi:10.1016/j.jpain.2025.105407 · Cited by 3 · see citing works
Self-citationLiliequist, B. E., Särnholm, J., Skúladóttir, H., Ólafsdóttir, E., Ljótsson, B., & Braunschweig, F. (2023) · JMIR Cardio · doi:10.2196/53815 · Cited by 3 · see citing works
Self-citationKallesøe, K. H., Ørnbøl, E., Wellnitz, K. B., & Rask, C. U. (2025) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2025.2521719 · Cited by 3 · see citing works
“The current findings corroborate results from studies in adults with both single system FSD (IBS) and multisystem FSD, where changes to more adaptive illness perceptions mediated the effect of CBT (Chilcot & Moss-Morris, 2013; Christensen et al., 2015).”
InfluentialLöfgren, E., Lindfors, P., Nilsson, K., Wannstedt, J., Bonnert, M., & Uusijärvi, A. (2023) · Gastrointestinal Disorders · doi:10.3390/gidisord6010001 · Cited by 2 · see citing works
“Furthermore, internet-CBT may work best for children and adolescents with increased levels of fear and avoidance behaviors related to the abdominal symptoms [23,24].”
Self-citationArbinaga, F., Vargas, G. A., & Moreno, E. (2025) · Perceptual and Motor Skills · doi:10.1177/00315125251365290 · Cited by 1 · see citing works
“This corresponds with studies showing how avoidance is associated with functioning and that addressing avoidance in exposure-based interventions can improve such functioning (Bonnert et al., 2018; Hedman-Lagerlof et al., 2018), in our case, that of referees.”
Soini, T., Andersson, F., Lalouni, M., Bonnert, M., Voghera, S., Ljótsson, B., Benninga, M. A., Vlieger, A. M., Rolandsdotter, H., Uusijärvi, A., et al. (2025) · Therapeutic Advances in Gastroenterology · doi:10.1177/17562848251381141 · Cited by 1 · see citing works
Self-citationIngram, K. M., Anderson, A. S., Luzincourt, D., Chun, S., Gorbounova, I., Pendse, S., Shapiro, J. M., Huang, J., & Nugent, N. R. (2026) · Neurogastroenterology & Motility · doi:10.1111/nmo.70326 · Cited by 1 · see citing works
“DGBI can also lead to functional impairment due to the perception of symptoms (e.g., abdominal pain) as threatening [6, 33], exemplified by tags for inferred impairment and explicit avoidance in the data.”
Thérapie cognitivo-comportementale pour les enfants atteints du syndrome du côlon irritable
Buffone, A., & Goldman, R. D. (2021) · Canadian Family Physician · doi:10.46747/cfp.6712e323
“Am J Gastroenterol 2017;112(1):152-62.”
InfluentialMohammadi, H., Afshar, H., Goli, F., Keshteli, A. H., & Abolmaali, K. (2022) · Middle East Journal of Digestive Diseases · doi:10.34172/mejdd.2022.307
Ebrahimi, A., Forghani, M., Bababkhanian, M., Ebrahimi, M., & Adibi, P. (2023) · Gastroenterology and hepatology from bed to bench. · doi:10.22037/ghfbb.v16i2.2440
“%) of the entire treatment effect was explained by a reduction in avoidance behavior based on IBS-BRQ (39).”
MethodCluster Analysis of Psychological Factors in Non-Patients with Irritable Bowel Syndrome
Kobayashi, K., So, Y., Yamada, T., & Fujii, Y. (2024) · Trends in Psychology · doi:10.1007/s43076-024-00389-w
Sugaya, N., Tomita, Y., Funaba, M., Iida, H., Shirotsuki, K., Gardner, F. C., Odawara, T., Ando, T., & Inamori, M. (2022) · Figshare · doi:10.6084/m9.figshare.20364918
Sugaya, N., Tomita, Y., Funaba, M., Iida, H., Shirotsuki, K., Gardner, F. C., Odawara, T., Ando, T., & Inamori, M. (2022) · Figshare · doi:10.6084/m9.figshare.20364915
Trindade, I. A., Pereira, A., Veloso, B., Gils, T. V., & Nybacka, S. (2026) · medRxiv · doi:10.64898/2026.02.23.26346871
- Authors
- Bonnert, M., Olén, O., Bjureberg, J., Lalouni, M., Hedman-Lagerlöf, E., Serlachius, E., & Ljótsson, B.
- Affiliations
- Region Stockholm (SE)
- Karolinska Institutet (SE)
- Corresponding author
- Bonnert, Marianne
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2018-06
- Volume
- 105
- Pages
- 27-35
- ISSN
- 0005-7967 (ISSN-L)
- OpenAlex
- W2794848059
- Cited by
- 53
- References
- 68
- Citations by year
- 2026: 3 · 2025: 10 · 2024: 6 · 2023: 6 · 2022: 9 · 2021: 10 · 2020: 3 · 2019: 4 · 2018: 2
- FWCI
- 4.53
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Behaviour Research and Therapy (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- Funders
- Jan and Dan Olsson Foundation (4-1559/2013)
- Swedish Research Council (521-2013-2846)
- Kempe-Carlgren Foundation, the Ruth and Richard Julin Foundation (2012Juli0048)
- Majblomman Foundation
- Ishizu Matsumurais Donation
- Bengt Ihre Foundation (SLS-331861)
- Bengt Ihre research fellowship in Gastroenterology
- Swedish Society of Medicine (SLS331681, SLS-410501)
- Gadelius Foundation, the Samariten Foundation
- Värkstadsstiftelsen Foundation
- Swedish Medical Society, the Stockholm County Council
- Swedish Research Council for Health, Working Life and Welfare (2014-4052)
- Stockholm County Council
- Karolinska Institutet (20130129)
- Topics
- Health Sciences › Medicine › Gastroenterology › Gastrointestinal motility and disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Keywords
- irritable bowel syndrome, adolescents, avoidance behavior, perceived stress, gastrointestinal symptoms, mediation analysis
- MeSH terms
- Adolescent, Avoidance Learning, Female, Humans, Implosive Therapy, Male, Quality of Life, Stress, Psychological, Cognitive Behavioral Therapy, Treatment Outcome, Irritable Bowel Syndrome
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