Biopsychosocial Aspects of Functional Gastrointestinal Disorders: How Central and Environmental Processes Contribute to the Development and Expression of Functional Gastrointestinal Disorders
Open accessAbstract
In this paper, we provide a general framework for understanding the functional gastrointestinal disorders (FGID) from a biopsychosocial perspective. More specifically, we provide an overview of the recent research on how the complex interactions of environmental, psychological, and biological factors contribute to the development and maintenance of the FGID. We emphasize that considering and addressing all these factors is a conditio sine qua non for appropriate treatment of these conditions. First, we provide an overview of what is currently known about how each of these factors - the environment, including the influence of those in an individual's family, the individual's own psychological states and traits, and the individual's (neuro)physiological make-up - interact to ultimately result in the generation of FGID symptoms. Second, we provide an overview of commonly used assessment tools which can assist clinicians in obtaining a more comprehensive assessment of these factors in their patients. Finally, the broader perspective outlined earlier is applied to provide an overview of centrally acting treatment strategies, both psychological and pharmacological, which have been shown to be efficacious to treat FGID.
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Chronic stress, psychological symptoms, negative beliefs about symptoms and illness and maladaptive coping mechanisms can increase the frequency and severity of symptoms in IBS.
“chronic stress, psychological symptoms, negative beliefs about symptoms and illness and maladaptive coping mechanisms can increase the frequency and severity of symptoms.29 30”
From British Society of Gastroenterology guidelines on the management of irritable bowel syndrome (2021) · cites this paper as [29]
The Environmental Influences section links chronic stress to exacerbation and intensity of IBS symptoms, while Psychological Distress says psychological symptoms can perpetuate or exacerbate FGID symptoms. The Psychological Treatments section discusses negative beliefs and avoidance as treatment targets, but does not clearly establish that maladaptive coping increases the frequency and severity of IBS symptoms. Page numbers were not provided in our copy. (LLM, conf=0.82)
Experimental — accuracy not yet measuredEarly-life adverse events, such as physical or sexual abuse, are prevalent in CNVS.
“and early‐life adverse events, such as physical or sexual abuse, are also prevalent [ 379 , 381 ].”
From European Guideline on Chronic Nausea and Vomiting—A UEG and ESNM Consensus for Clinical Management (2025) · cites this paper as [379]
A stressful life and emotional events are associated with symptom exacerbation in CNVS.
“A stressful life and emotional events are associated with symptom exacerbation [ 376 , 379 , 380 ]”
From European Guideline on Chronic Nausea and Vomiting—A UEG and ESNM Consensus for Clinical Management (2025) · cites this paper as [379]
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Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction
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Self-citationACG Clinical Guideline: Management of Irritable Bowel Syndrome
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“GDPs have been well-tested as adjunctive tomedical therapies in moderate to severe IBS against a range of active and inactive control groups (247).”
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Self-citationBritish Society of Gastroenterology guidelines on the management of irritable bowel syndrome
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“29 30 For some patients with IBS, psychological comorbidity or distress may be a consequence, rather than a cause, of the severity and frequency of symptoms experienced.”
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“the most common psychiatric comorbidity in functional GI disorder patients [10].”
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“Knowledge of IBS’s correlation with psychiatric disorders would enhance understanding and treatment of IBS patients, as psychological distress could exacerbate symptoms, negatively affect treatment outcomes, and affect doctor-patient relationships.(4) The aim of this meta-analysis was to compare depression and anxiety…”
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“Functional gastrointestinal disorders in general can be understood from a biopsychosocial perspective (Van Oudenhove et al., 2016), and this is particularly true of IBS: there is a high prevalence of early life stress in IBS patients compared to inflammatory bowel disease, an organic disease with…”
Improving Patient-Provider Relationships to Improve Health Care
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“Thus, learning the illness experience from the patient leads to proper diagnosis which is then correlated with the pathological or physiological features (21).”
Self-citationFear in the context of pain: Lessons learned from 100 years of fear conditioning research.
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“24 25 Previous studies have shown that among the broad class of individuals affected by GERD, those with functional oesophageal disorders typically have normal oesophageal acid exposure 26 , and this may lead to them having lower risk of downstream BE/EA compared with other patients with GERD.”
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“his/her knowledge about how to successfully facilitate referrals for such treatments, many patients do not receive care at all,(13) or do so too late in the process, when selfmanagement has failed and refractory psychopathology and/or inflammatory disease have developed.(2) There is also mounting evidence that stress…”
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“Summary of evidence: The prevalence of psychiatric illnesses in IBS patients is controversial, but IBS consulters often complain of psychological and somatoform symptoms.(13) Van Tilburg et al.”
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“The biopsychosocial model was first applied to IBS by Doug Drossman, MD.(11,12) This model emphasizes interactions between biology (eg, genetic predisposition, disordered gut motility, altered gut microbiota, low-grade inflammation), behavior (eg, illness behaviors, symptom avoidance), cognitive processes (eg, brain–g…”
Validation of the oesophageal hypervigilance and anxiety scale for chronic oesophageal disease
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“Additionally, when psychological factors accompany this condition, the treatment of the functional gastrointestinal disorder becomes difficult, which contributes to poor outcomes.(10) To date, a few studies describing GERD have shown that psychological factors, particularly anxiety and depression, play an important ro…”
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“, catastrophizing, prediction error), stress reactivity, and hypervigilance to threat cues [12, 13].”
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Italian guidelines for the management of irritable bowel syndrome
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“However, the prevalence of overlapping psychological comorbidities in patients with IBS is controversial [17].”
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“Inclusion of covariates is recommended in order to reduce bias in mediation effect estimates, and leads to a greater understanding of the influence of potential confounding variables (MacKinnon and Pirlott, 2015, Mackinnon et al., 2007, VanderWeele, 2015).”
InfluentialGanci, M., Suleyman, E., Butt, H., & Ball, M. (2019) · Brain and Behavior · doi:10.1002/brb3.1408 · Cited by 71 · see citing works
“…can be noticeably unpleasant and, particularly in IBS sufferers, can lead to impairment in daily functioning (Ballou, Bedell, & Keefer, 2015), anxi‐ ety and depression (Roohafza et al., 2016), avoidance behaviors (Van Oudenhove et al., 2016), and poor quality of life (Canavan, West, & Card, 2015).”
BackgroundBehavioural medicine and gastrointestinal disorders: the promise of positive psychology
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“Nevertheless, nonpharmacologic interventions may be better suited for addressing the multifactorial biological, psychological, and social framework in which functional GI symptoms develop.(4) We found that stress and mental health counseling were underused in this patient population, despite the established associatio…”
Review article: Physical and psychological comorbidities associated with irritable bowel syndrome
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“Besides the orexigenic hormone ghrelin, anorexigenic hormones such as PYY have also been shown to modulate reward system function and food reward responses in healthy subjects.”
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Central neuromodulators for treating functional GI disorders: a primer
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“It is well-known that patients with IBS often show psychiatric comorbidities such as anxiety and depression,(9-11) but may also present with multiple, medically unexplained extraintestinal symptoms.(12,13) Moreover, the presence of extraintestinal and psychological symptoms affects the outcome in patients with IBS, wh…”
BackgroundCultural Factors Influencing Functional Gastrointestinal Disorders in the East
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Functional Bowel Disorders: A Roadmap to Guide the Next Generation of Research
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“Psychosocial factors can affect the gut physiology via the brain–gut axis in IBS [10, 16].”
The interplay between microbiota and brain-gut axis in epilepsy treatment
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Guidelines on the management of irritable bowel syndrome
Pietrzak, A. M., Skrzydło-Radomańska, B., Mulak, A., Lipiński, M., Malecka-Panas, E. I., Reguła, J., & Rydzewska, G. M. (2018) · Gastroenterology Review · doi:10.5114/pg.2018.78343 · Cited by 56 · see citing works
“Central nervous system disorders are also associated with dysregulation of the autonomic nervous system, which may explain the occurrence of a wide spectrum of parenteral symptoms in patients with IBS, such as headache, back pain, fibromyalgia, sleep disorders, chronic fatigue syndrome or anxiety-depressive disorders…”
Nakagawa, K., Sawada, A., Hoshikawa, Y., Nikaki, K., Gabieta-Sonmez, S., Woodland, P. J., Yazaki, E. T., & Sifrim, D. A. (2019) · The American Journal of Gastroenterology · doi:10.14309/ajg.0000000000000295 · Cited by 55 · see citing works
Alexithymia in Gastroenterology and Hepatology: A Systematic Review
Carrozzino, D., & Porcelli, P. (2018) · Frontiers in Psychology · doi:10.3389/fpsyg.2018.00470 · Cited by 54 · see citing works
“All the other studies included in this review (Porcelli et al., 2004, 2014b; Jones et al., 2006, 2013; van Kerkhoven et al., 2006; Farinelli et al., 2007; Van Oudenhove et al., 2011b; Phillips et al., 2013; Eiroa-Orosa et al., 2015; Dibaise et al., 2016) were cross-sectional.”
InfluentialNisticò, V., Rossi, R. E., D'Arrigo, A. M., Priori, A., Gambini, O., & Demartini, B. (2022) · Journal of Neurogastroenterology and Motility · doi:10.5056/jnm21079 · Cited by 52 · see citing works
Grover, M., Kolla, B. P., Pamarthy, R., Mansukhani, M. P., Breen‐Lyles, M. K., He, J.-P., & Merikangas, K. R. (2021) · PLoS ONE · doi:10.1371/journal.pone.0245323 · Cited by 50 · see citing works
“Psychological distress is an independent risk factor for development of IBS and can exacerbate or perpetuate symptoms [7].”
BackgroundInfluentialGut‐brain axis dysfunction underlies FODMAP ‐induced symptom generation in irritable bowel syndrome
Wu, J., Masuy, I., Biesiekierski, J. R., Fitzke, H., Parikh, C. R., Schofield, L., Shaikh, H. U., Bhagwanani, A., Aziz, Q., Taylor, S. A., et al. (2022) · Alimentary Pharmacology & Therapeutics · doi:10.1111/apt.16812 · Cited by 51 · see citing works
Hypnosis and Cognitive Behavioral Therapies for the Management of Gastrointestinal Disorders
Palsson, O. S., & Ballou, S. (2020) · Current Gastroenterology Reports · doi:10.1007/s11894-020-00769-z · Cited by 49 · see citing works
Esophageal hypervigilance is prevalent across gastroesophageal reflux disease presentations
Guadagnoli, L. A., Yadlapati, R. H., Taft, T., Pandolfino, J. E., Tye, M. Y., & Keefer, L. (2021) · Neurogastroenterology & Motility · doi:10.1111/nmo.14081 · Cited by 49 · see citing works
Self-citationPolster, A. V., Palsson, O. S., Törnblom, H., Öhman, L., Sperber, A. D., Whitehead, W. E., & Simrén, M. (2018) · Neurogastroenterology & Motility · doi:10.1111/nmo.13483 · Cited by 47 · see citing works
Association Between Alexithymia and Functional Gastrointestinal Disorders
Kano, M., Endo, Y., & Fukudo, S. (2018) · Frontiers in Psychology · doi:10.3389/fpsyg.2018.00599 · Cited by 49 · see citing works
“FGIDs have been studied from a biopsychosocial perspective and shown that psychological and social factors have an impact on FGIDs (Van Oudenhove et al., 2016).”
BackgroundAlexithymia and Physical Illness: A Psychosomatic Approach
Porcelli, P., & Taylor, G. J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781108241595.009 · Cited by 47 · see citing works
Groen, J., Gordon, M. A., Chogle, A. S., Benninga, M. A., Borlack, R. E., Borrelli, O., Darbari, A., Dolinšek, J., Khlevner, J., Lorenzo, C. D., et al. (2025) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1002/jpn3.70070 · Cited by 56 · see citing works
Irritable Bowel Syndrome and Depression: A Shared Pathogenesis
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Self-citationCognitive Behavioral Therapy for IBS: How Useful, How Often, and How Does It Work?
Radziwon, C. D., & Lackner, J. M. (2017) · Current Gastroenterology Reports · doi:10.1007/s11894-017-0590-9 · Cited by 42 · see citing works
Self-citationImplementing psychological therapies for functional GI disorders in children and adults
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Development and Current State of Digital Therapeutics for Irritable Bowel Syndrome
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Basilisco, G., & the Italian Society of Neurogastroenterology Motility (SINGEM) Study Group (2020) · Alimentary Pharmacology & Therapeutics · doi:10.1111/apt.15657 · Cited by 43 · see citing works
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“It may be related to the brain-gut axis [16–20], through which psycho-social factors can influence gut physiology and trigger gastro-intestinal symptoms [21].”
Chronic colitis-induced visceral pain is associated with increased anxiety during quiescent phase
Salameh, É., Méleine, M., Gourcerol, G., do-Rego, J.-C., do Rego, J. L., Legrand, R., Breton, J., Aziz, M., Guérin, C., Coëffier, M., et al. (2019) · American Journal of Physiology-Gastrointestinal and Liver Physiology · doi:10.1152/ajpgi.00248.2018 · Cited by 40 · see citing works
Gut microbiota and irritable bowel syndrome: status and prospect
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Depression and Anxiety in Patients with Gastroesophageal Reflux Disorder With and Without Chest Pain
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“Also, the interplay between psychosocial and physiological factors via the interactions between the central nervous system (CNS) and the enteric nervous system (ENS) is thought to influence IBS expression (11).”
BackgroundGrinsvall, C., Törnblom, H., Tack, J., Oudenhove, L. V., & Simrén, M. (2018) · United European Gastroenterology journal · doi:10.1177/2050640617715851 · Cited by 32 · see citing works
“Colorectal hypersensitivity is an important pathophysiological mechanism in IBS.(1) It has been associated with overall IBS symptom severity, and pain and bloating in particular.”
BackgroundInfluentialAlbusoda, A., Ruffle, J. K., Friis, K. A., Gysan, M. R., Drewes, A. M., Aziz, Q., & Farmer, A. D. (2018) · Alimentary Pharmacology & Therapeutics · doi:10.1111/apt.14965 · Cited by 35 · see citing works
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Psychotherapeutic Interventions in Irritable Bowel Syndrome
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Associative learning and extinction of conditioned threat predictors across sensory modalities
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Revolutionizing Gastrointestinal Disorder Management: Cutting-Edge Advances and Future Prospects
Suri, C., Pande, B., Sahu, T. A., Sahithi, L. S., & Verma, H. K. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13133977 · Cited by 32 · see citing works
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Hanel, V., Schalla, M. A., & Stengel, A. (2021) · European Eating Disorders Review · doi:10.1002/erv.2847 · Cited by 31 · see citing works
“If necessary, this should be incorporated better in the treatment of EDs, as it is likely that FGIDs/FGID symptoms arise due to a complex interplay of biological, psychological and social factors (Van Oudenhove et al., 2016).”
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“Similarly, poor GI health may trigger anxiety and depression in the patients [8,9].”
BackgroundBlakey, S. M., Halverson, T. F., Evans, M. K., Patel, T. A., Hair, L. P., Meyer, E. C., DeBeer, B. B., Beckham, J. C., Pugh, M. J., Calhoun, P. S., et al. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.07.033 · Cited by 31 · see citing works
Sangnes, D. A., Lundervold, K., Bekkelund, M., von Volkmann, H. L., Berentsen, B., Gilja, O. H., Dimcevski, G. G., & Søfteland, E. W. (2021) · United European Gastroenterology Journal · doi:10.1002/ueg2.12169 · Cited by 31 · see citing works
“However, the relationship between mental status and gastrointestinal symptoms is likely bidirectional: whereas mood disorders may lead to hypervigilance and altered interpretation of symptoms, they may also be a consequence of the disease burden.(31) Finally, while not finding any difference in transit times comparing…”
Reed-Knight, B., van Tilburg, M. A. L., Levy, R. L., Langer, S. L., Romano, J. M., Murphy, T. B., DuPen, M. M., & Feld, A. D. (2018) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsx082 · Cited by 30 · see citing works
“There is some evidence that both anxiety and gastrointestinal (GI) symptom severity are associated with brain regions commonly activated in response to fear, suggesting a potential mechanism by which negative emotions may impact GI symptoms (Drossman, 2005; Van Oudenhove et al., 2016).”
Background
- Authors
- Van Oudenhove, L., Levy, R. L., Crowell, M. D., Drossman, D. A., Halpert, A. D., Keefer, L., Lackner, J. M., Murphy, T. B., & Naliboff, B. D.
- Affiliations
- University of Washington (US)
- Mayo Clinic (US)
- University of North Carolina at Chapel Hill (US)
- Boston Medical Center (US)
- Mount Sinai Hospital (US)
- State University of New York (US)
- University of California, Los Angeles (US)
- Corresponding author
- Levy, Rona L.
- ORCID
- Venue
- Gastroenterology
- Publisher
- Elsevier BV
- Published
- 2016-05
- Volume
- 150
- Issue
- 6
- Pages
- 1355-1367.e2
- ISSN
- 0016-5085 (ISSN-L)
- PMC
- PMC8809487
- OpenAlex
- W2344812785
- Cited by
- 512
- References
- 110
- Citations by year
- 2026: 49 · 2025: 58 · 2024: 54 · 2023: 52 · 2022: 59 · 2021: 63 · 2020: 51 · 2019: 47 · 2018: 35 · 2017: 38 · 2016: 6
- FWCI
- 45.98
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Gastroenterology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Allergan
- National Institute of Diabetes and Digestive and Kidney Diseases (U01DK077738)
- Topics
- Health Sciences › Medicine › Gastroenterology › Gastrointestinal motility and disorders
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- functional gastrointestinal disorders, biopsychosocial model, environmental factors, psychological factors, family influence, psychological characteristics, neurophysiological factors, psychological assessment instruments, pharmacotherapy, psychological intervention, treatment options
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