If you’ve ever strolled through the aisles of your local bookstore or library, there’s a decent chance you came across a section devoted entirely to books on stress management. Similarly, a quick Google search using the phrase stress management returns a dizzying assortment of websites that offer all kinds of schemes for reducing stress. The purpose of this chapter isn’t to cover every conceivable intervention for managing stress and anxiety; instead, I detail the strategies that have also been used to reduce gut dysfunction.
There’s one important qualifying point to keep in mind regarding much of the science discussed in this chapter, and that is most of the studies I reference were carried out in people experiencing gut symptoms because of underlying gastrointestinal disorders. As much as I’d like to say these strategies have a proven track record of alleviating gut symptoms that arise from competition stress and anxiety, I have an obligation to be completely transparent about what the science really says. And unfortunately, there’s little to no research available to tell us how well these strategies work for dealing with competition anxiety or its associated gut problems. On the bright side, most of these interventions come with minimal serious risks, although some (such as prescription drugs) have side effects and require oversight from a healthcare provider.
BREATHING
Manipulating one’s breath has been used for millennia—often in conjunction with other practices like mindfulness and prayer—to achieve a sense of oneness or spiritual enlightenment. In recent decades, breathing exercises have become mainstream, having made their way from Buddhist temples into health clinics. Indeed, interventions that manipulate the breath have become increasingly utilized in the management of a growing list of health problems—anxiety, depression, panic disorder, asthma, heart disease. There are numerous styles of breathing to choose from: slow and deep; fast and shallow; in through the nose, out through the mouth; focusing on breathing with the belly. Each of these means can lead to disparate ends, making it tricky to generalize about the effects of breathing interventions. When it comes to improving gut problems, though, slow deep breathing has the most scientific oomph behind it.
Although I didn’t discuss motion sickness in Chapter 2, nausea is universally recognized as one of its most common and debilitating symptoms. And because motion sickness is so easy to induce (try slowly spinning in a chair if you don’t believe me), it makes for a convenient model of studying how various interventions impact nausea. Interestingly, slow deep breathing is one of many interventions that scientists have trialed as a motion sickness remedy. The physiological basis for thinking that slow deep breathing would mitigate nausea has to do with its effects on the autonomic nervous system. At rest, the parasympathetic (rest-and-digest) branch of your autonomic nervous system is more active than the sympathetic (fight-or-flight) branch. At the onset of motion sickness, there’s a reduction in parasympathetic activity along with a parallel uptick in sympathetic activation.1 What’s more, larger decreases in parasympathetic activity correlate with greater severities of motion sickness.2
Based on these facts, it is logical to think that anything that prevents a shift from parasympathetic to sympathetic dominance has the potential to relieve motion sickness. And in fact, experiments do show that slow deep breathing consistently increases parasympathetic activity3 and seems to lessen the severity of motion sickness.4–6 In one illustrative study, college students spent 10 minutes wearing 3-D goggles that simulated stormy seas.5 Sounds like fun, right? Half of the participants practiced slow deep breathing during the simulation while the other half observed themselves and their environment. Participants rated nausea on a 1-to-4 scale, and by the 10th minute, those in the slow deep breathing group rated their nausea at 1.5, while those in the attentional control group rated nausea roughly 30 percent higher.
How exactly can these findings be applied to athletes? That’s a difficult question to answer, as nausea induced in a laboratory isn’t necessarily the same as nausea that arises because of pre-game nerves or from sprinting or ultraendurance exercise. Theoretically, though, slow deep breathing could help manage any form of nausea that’s exacerbated by excessive sympathetic nervous system activation. As such, pre-competition queasiness associated with extreme levels of stress and anxiety seems like a form of nausea that’s likely to benefit from slow deep breathing, and this was even mentioned as a strategy that Brandon Brooks planned to use before Super Bowl LII.7
Other than nausea, several gut symptoms have the potential to be managed through the practice of slow deep breathing. Take for example functional dyspepsia, a cluster of chronically occurring symptoms that includes fullness after eating, premature satiation, epigastric (upper abdomen) pain, and epigastric burning.8 Although many people are only vaguely aware of it, the worldwide prevalence of functional dyspepsia is between 11.5 percent and 29.2 percent.9 Sympathetic-parasympathetic nervous system balance is often disturbed in patients with functional dyspepsia,10 which provides an underlying rationale for how slow deep breathing could improve its symptoms. Unfortunately, few studies have tested the effectiveness of slow deep breathing in patients with functional dyspepsia, although one experiment found that, compared to a control group that did nothing, daily slow deep breathing for five minutes improved quality of life and increased the amount of soup that patients could tolerably consume in one sitting.11
Similar to functional dyspepsia, IBS is another prevalent gut disorder that’s associated with a state of sympathetic nervous system predominance.12 Even though studies have included breathing exercises as a part of multicomponent interventions (e.g., yoga) for IBS, few of them isolated the effects of slow deep breathing. As a result, it’s not clear what effect slow deep breathing has on quality of life and gut symptoms in people with IBS.
In sum, research has clearly documented the power of slow deep breathing to manipulate sympathetic-parasympathetic nervous system activity. However, further research is needed to truly confirm or refute whether slow deep breathing offers significant relief for athletes and to determine what protocols are most practical, efficient, and effective. Still, for athletes who are troubled by gut symptoms arising from psychological stress or anxiety, slow deep breathing is one tactic that they could give a shot. A simple daily protocol to follow is to target four to six breaths per minute, with exhalations lasting slightly longer than inspirations, for 10–15 minutes total.
MINDFULNESS
The practice of mindfulness involves focusing your attention on the present moment. It can include monitoring your thoughts, emotions, and bodily sensations, as well as being more aware of your surroundings. Focusing on your breath, noticing the way your feet feel against the ground, and lingering over the tastes and textures of food are all examples of practicing mindfulness. In essence, mindfulness is a form of meditation.
Mindfulness interventions have been tested in a broad range of health conditions, but mood disorders have probably received the most attention. The results of several comprehensive analyses of mindfulness interventions suggest they’re efficacious and cost-effective for improving symptoms of anxiety in people diagnosed with anxiety disorders.13, 14 Exactly why mindfulness seems to boost mood and diminish anxiety isn’t entirely clear, but one possibility is that it might limit the ruminating and worrying thoughts that are so common in people living with anxiety and depressive disorders.15
Albeit to a lesser extent than with slow deep breathing, there’s some evidence that being mindful can increase parasympathetic nervous system activity,16, 17 and as is the case with slow deep breathing, modulation of the autonomic nervous system could explain why a number of experiments have found reductions in symptoms when patients with chronic gut disorders implement mindfulness-based interventions.18, 19 That said, most of these trials were done in patients with IBS, and mindfulness was often just one component of a multipronged treatment approach. As a result, it’s hard to say what effect mindfulness training would have in athletes other than those diagnosed with IBS.
While there are many ways to practice mindfulness, it might be particularly effective to combine it with slow deep breathing. You can do this by noticing how it feels as the air passes in and out of your nose or how your chest and abdomen rise and fall with each breath or by counting breaths until your reach a certain number (e.g., 50).
EXERCISE TRAINING
Acute exercise can bring about a multitude of annoying—and sometimes even debilitating—gut symptoms. One might assume, then, that long-term exercise training does the same. In most cases though, this is not the case. In fact, experiments reveal that exercise training blunts the typical reductions in gut blood flow that occur during acute exercise,20 and these findings are bolstered by studies demonstrating that seasoned runners typically suffer from fewer gut symptoms while exercising than their novice counterparts.21–23
What remains unclear is the extent to which declines in anxiety are responsible for these reductions in gut symptoms over time with exercise training. Overall, aerobic training24, 25—as well as resistance training,26 yoga,27 and Tai Chi28—seem to modestly dampen anxious thoughts and feelings. The question, then, is whether these reductions in anxiety translate to fewer anxiety-related digestive problems. Regrettably, these studies didn’t collect information on gut symptoms. Perhaps the most promising evidence tying long-term exercise training to decreases in anxiety-related gut symptoms comes from studies of IBS patients, many of whom deal with anxiety issues. In at least two trials, increasing physical activity lessened gut symptoms in people with IBS.29, 30 Similarly, the results from a half-dozen trials suggest that yoga improves quality of life and eases gut symptoms in IBS.31
HYPNOSIS
Ritualistic ceremonies and practices bearing a resemblance to modern-day hypnosis have been performed throughout recorded history. The Egyptians, for instance, supposedly induced sleeplike trance states millennia before European physicians started dabbling in practices similar to hypnosis.32 Today, hypnosis is often considered by traditional healthcare practitioners as an alternative medicine that should be reserved for situations where modern treatments fail to elicit favorable responses. Nevertheless, millions of people—even in Western societies—try hypnosis every year. In the 1990s, a survey of Americans found that roughly 1 percent of adults had used hypnosis over the previous year.33 More recent surveys put these estimates closer to 0.1–0.2 percent, indicating that hypnosis may be falling out of favor, at least in the US.34
Hypnosis is notoriously difficult to study, in large part due to the varied techniques that can be utilized to induce hypnotic states as well as the high likelihood of placebo/expectation effects. Bear in mind, it’s essentially impossible to blind research participants to the fact that they’re being hypnotized. This reality, in combination with the fact that many hypnosis experiments are of poor methodological quality, makes it challenging to glean useful insights from the research on hypnosis and anxiety.35
These caveats aside, clinical trials of patients with IBS provide some thin evidence that hypnosis can diminish gut symptoms in comparison to no intervention or usual medical management.36, 37 Exactly how hypnosis would achieve improvements in gut discomfort and other forms of pain remains mostly a mystery, even in an age when we can probe the brain noninvasively. While it’s unequivocal that hypnosis modifies brain activation patterns, the particular regions involved frequently differ between studies.38
Like with many of the other interventions that are presented here, there’s essentially no research available to tell us how hypnosis influences psychologically induced gut symptoms in sports. Thus, any athlete who uses hypnosis in an attempt to alleviate gut symptoms from competition nerves is doing so largely in the absence of concrete evidence. Lastly, it’s important to keep in mind that, although hypnosis is thought to be relatively safe, it isn’t completely risk-free.39
MUSIC
Nowadays, the sight of athletes wearing headphones as they walk off their team bus or enter a stadium is ubiquitous. The image of Michael Phelps listening to music before his swimming events during the 2016 Rio Olympics (while also giving rival South African swimmer Chad le Clos the death stare) is an iconic example of this sort of precompetition routine. At the Winter Olympics, it’s not uncommon to see snowboarders pull out a pair of earbuds just as they finish a run down the half-pipe. American snowboarding legend Shaun White’s 2018 Olympics playlist on Spotify included motivational tracks like “Iron Man” by Black Sabbath and “Immigrant Song” by Led Zeppelin. In contrast, Japanese silver medalist Ayumu Hirano shared that one of his favorite jams to listen to around competition time is Bob Marley’s “Three Little Birds” because of its calming effects.40
Beyond these anecdotes, studies substantiate the idea that many athletes listen to music before competition to get a psychological boost. A study of 195 collegiate athletes from the United Kingdom found that 24 percent listened to fast, upbeat music on the day of competition, while another 21 percent listened to slow, soft music.41 In a similar survey of 252 Swedish athletes, the pre-competition period was the most popular time for athletes to listen to music, surpassing other periods like training and competition itself.42
For athletes who rely on music to calm their nerves, what’s the evidence that it does any good? Surprisingly, few studies have addressed this question in detail or in the realm of real-life competition. In one example, a group of college athletes listened to a three-minute selection of self-chosen music prior to actual competition while a control group went sans music.43 Although the music listeners reported higher self-confidence levels after the intervention, these ratings were collected roughly 30–105 minutes before competition, so it’s unclear whether their self-assuredness persisted into competition.
In another study, undergraduate students were told they would be partaking in a skills competition and—to induce more anxiety—that there may be an audience present or that they might be filmed.44 Then the students were assigned to a relaxing-music condition, a nonrelaxing-music condition, or a no-music condition, and each was applied for 10 minutes before the students threw beanbags at a 1-meter hoop on the floor that was 7 meters away. Although some of the data were suggestive of a benefit of relaxing music on anxiety, there were no clear, unambiguous differences between the groups. Furthermore, average performance on the beanbag-throwing task was similar in all groups.
Even though there isn’t much direct evidence that relaxing music reduces anxiety before sporting competition, studies looking at music listening in other stressful situations support the notion that it can calm a person’s worries and dampen physiological arousal. Combined data from 19 scientific publications reveal that music eases self-reported anxiety in healthy adults,45 and similar benefits have been found in individuals undergoing medical procedures like cardiac catheterizations.46, 47 These findings—in addition to the ardent beliefs that many athletes have about the power of music—provide justification for its application as a potentially valuable tool to be used in and around the time of competition.
In terms of gut function before or during competition, very little is known about the effects of music. Unlike some of the other interventions that have been discussed so far, there isn’t much research on how music impacts conditions like IBS and functional dyspepsia. Although some studies have used music as a part of a larger relaxation intervention for these disorders, the independent effects of music remain unknown.
COGNITIVE BEHAVIORAL THERAPY (CBT)
As opposed to more antiquated forms of psychotherapy—such as Freud’s psychoanalysis—cognitive behavioral therapy (CBT) is backed by literally hundreds of clinical trials. The basic idea behind CBT is that a person’s maladaptive thoughts, beliefs, and attitudes contribute to mood disturbances and cause them to engage in unhelpful behaviors. An example would be a woman who thinks she always comes off as being awkward at social gatherings (a maladaptive thought), which causes her to avoid those situations to the detriment of her psychological health (an unhelpful behavior). The anxiety that often accompanies these maladaptive thoughts can trigger physical symptoms, including gut woes.48 Consequently, various forms of CBT have been used not only in the treatment of mood disorders but also IBS and functional dyspepsia.
When someone undergoes CBT, a variety of exercises and techniques are used to help root out and address the thoughts and behaviors that are causing problems for them. Journaling is frequently involved, as it can help link thoughts, beliefs, and behaviors to identify patterns and tendencies that can be targeted for therapy. Then a therapist may ask a client to work on challenging or restructuring the maladaptive thoughts and beliefs that were identified through journaling. A client might also start engaging in other pleasant or enjoyable activities that can improve mood or function (relaxation, meditation, exercise, etc.).
Overall, CBT is at least moderately effective for treating all kinds of anxiety disorders,49, 50 and therapist-guided, self-guided, group-based, and internet-delivered variations are all viable options. Given the obvious role that people’s thoughts play in determining their mood states, it’s not surprising that CBT can dampen anxiety and improve mood. What may come as a surprise is just how effective CBT can be for taming the physical symptoms experienced by people living with IBS and functional dyspepsia. A 2013 article in Clinical Gastroenterology and Hepatology found that CBT reduced symptoms or improved quality of life in about 90 percent of 30 studies that included people with functional gut disorders (IBS, dyspepsia, etc.).48
Given how effective CBT is for improving both anxiety and gut symptoms in individuals living with disorders like IBS, it seems like a no-brainer that CBT could help hyperamped athletes manage pre-competition nerves. One form of CBT—known as rational emotive behavior therapy (REBT)—has been applied in sports ranging from triathlon to archery to golf. Martin Turner, a senior lecturer at Staffordshire University in the United Kingdom, has been involved with numerous case studies claiming that REBT not only diminishes anxiety and irrational beliefs but also boosts athletic performance.51 Unfortunately, large experiments with control groups testing the effectiveness of REBT and other forms of CBT for easing anxiety and improving performance in athletes are few and far between, and the same is true when it comes to CBT’s role in ameliorating competition-induced gut symptoms.
ACCEPTANCE AND COMMITMENT THERAPY (ACT)
Although CBT is the most studied form of psychotherapy in the treatment of gut disorders, it’s by no means the only game in town. Steven Hayes, a psychologist and professor at the University of Nevada, Reno, is widely credited as the founder of a psychotherapy technique known as acceptance and commitment therapy (ACT).52 Even though ACT and CBT are both behavioral-based therapies and share several features, there are some distinctions to be made between these two contemporary psychotherapies. One of the main goals of CBT is to change maladaptive thoughts to more constructive cognitions. Instead of changing these thoughts and feelings, ACT teaches people to accept them without judgment.53 This process of accepting negative thoughts and feelings means that a person should learn to observe them more passively and respond to them less reactively. In essence, it’s designed to help people deal with the natural ups and downs of life.
The evidence base supporting ACT for anxiety disorders is fairly strong, with improvements reaching similar levels as CBT.54 However, in comparison to CBT, less research has been devoted to the use of ACT in gut disorders, and although there are some initial promising results, more work in these populations is needed.55 Likewise, there isn’t much we can say, scientifically speaking, about the utility of ACT for managing competition-related anxiety and its associated gut symptoms.
PHARMACEUTICAL DRUGS
The treatment of mood disorders prior to the advent of pharmaceutical drugs was often ineffective, unpleasant, and sometimes even deadly. Examples from the pages of history include the lobotomy, bloodletting, poison-induced vomiting, and even being burned alive.56 As the 1950s came around, a number of new drugs started to be used in patients with depression, one of the first of these being iproniazid. Interestingly, iproniazid wasn’t originally intended to be used as an antidepressant but rather as a tuberculosis remedy. However, clinicians using it in tuberculosis patients noticed “side effects” such as euphoria and improved sleep, and these observations prompted a group of researchers to test the drug in psychiatric patients. The results of that study, published in 1957, showed that 70 percent of patients demonstrated at least some mood improvements while on iproniazid.57 Soon thereafter, several hundred thousand people with depression were taking iproniazid until it was removed from the market in 1961 because of reports of liver toxicity.56
Around the same time that iproniazid was being tested as an antidepressant, another drug called imipramine was developed as an antipsychotic. Imipramine has a chemical structure similar to chlorpromazine, an antipsychotic drug that was introduced as a treatment for psychiatric patients in the mid-1950s.58 A Swiss drug company asked a psychiatrist named Roland Kuhn to test a number of novel but chemically similar compounds they thought would have similar effects as chlorpromazine, including imipramine.59 Although imipramine didn’t end up exhibiting antipsychotic effects in schizophrenics, Kuhn observed that it elevated mood in patients who were also suffering from major depressive symptoms. Subsequent studies confirmed the antidepressant effects of imipramine, and today it’s still occasionally used for treating depression.
In the two decades that followed the introduction of iproniazid and imipramine, numerous other antidepressants hit the market. Yet virtually all these new drugs were of the same class as either iproniazid, a monoamine oxidase inhibitor, or imipramine, a tricyclic antidepressant. It wasn’t until the introduction of selective serotonin reuptake inhibitors (SSRIs) in the 1980s that a new generation of antidepressants was made available. Today, SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the most popular types of antidepressants in the world. In addition to their widespread use for depression, SSRIs and SNRIs are commonly used in anxiety disorders, and along with CBT, they’re viewed by many as the first treatment options.60, 61
Interestingly, poor mood isn’t the only target of these drugs. Functional dyspepsia and IBS also respond to some types of antidepressants. In one meta-analysis of placebo-controlled trials, IBS patients who were given placebo pills were more likely to show no improvement in symptoms than those given the real SSRIs (67 percent versus 45 percent).37 Similar results were found for tricyclic antidepressants, with 64 percent of those given a placebo nonresponding versus 43 percent of those given the active drug. On the downside, more of the patients given the antidepressant drugs had side effects, although most of them were considered minor. In reference to functional dyspepsia, only tricyclic antidepressants have shown consistent positive effects on gastrointestinal symptoms.62
I’m sure this is beginning to sound all too familiar, but we currently know next to nothing (scientifically speaking) about how antidepressants affect an athlete’s gut. Obviously, if an athlete is diagnosed with IBS or functional dyspepsia, the use of anti-depressants will hopefully translate to fewer gut symptoms throughout the day as well as during training and competition, but that is yet to be verified in controlled experiments.
A FEW OTHER INTERVENTIONS
I’ve covered some of the most popular interventions used to manage disorders associated with excessive stress and anxiety as well as IBS and functional dyspepsia. There are numerous other treatments and approaches out there, and it would be impractical to cover every one of them in detail. A sampling of other interventions is summarized below.
Acupuncture. The practice of acupuncture, which usually involves inserting needles into specific points (a.k.a. acupoints) on the body, probably originated in China several thousands of years ago.63 According to a meta-analysis, acupuncture does a superior job of treating IBS in comparison to sham procedures or usual care.64 (In case you’re wondering, sham acupuncture involves placing needles in non-acupoints or touching them to the skin without penetrating it.) For functional dyspepsia, there are some positive data suggesting a benefit, but because many of the studies have been of low quality, strong conclusions about acupuncture’s effectiveness aren’t currently warranted.65
Biofeedback. Dysregulation of bodily systems contributes to a host of medical maladies, including mood disorders. The presence of an anxiety disorder, for instance, is associated with inadequate parasympathetic nervous system activity.66 Biofeedback is a technique that helps a person gain control over this physiological dysregulation for the purpose of improving health and/or performance. During biofeedback training, a person is connected to an instrument capable of monitoring physiological responses, allowing them to observe in real-time how various interventions (relaxation, deep breathing, etc.) can be used to manipulate these responses. Physiological parameters commonly monitored include breathing rate, heart rate, muscle activity, brain activity, temperature, and electrical conductivity of the skin.67 Given all the bodily systems that can be monitored—as well as all the different forms of training that can be used to manipulate these systems—it’s challenging to make straightforward conclusions about biofeedback training and anxiety symptoms. Even so, enough positive evidence is available to say that biofeedback training is a viable option in the armamentarium of treatments for anxiety.67, 68 There’s limited research on the use of biofeedback in isolation for conditions like IBS and functional dyspepsia, but some preliminary data suggest it could be helpful.69, 70
Probiotics. It may seem like a fantastically weird idea that microorganisms in your gut can impact your mood, but evidence from numerous studies (albeit mostly using animals) does in fact show this to be true.71 Exactly how these microbes could influence mood is still being investigated, but some of the likely pathways include activation of neuronal circuits in the gut and modulation of the hypothalamic-pituitary-adrenal axis, which is the body’s primary stress response system. In light of these discoveries, researchers have begun testing probiotics for improving anxiety and depressive symptoms in humans. Unfortunately, the combined results from 12 clinical trials (with more than 1,500 participants) indicate that probiotics aren’t particularly effective at alleviating anxiety.72 This analysis, published in Depression and Anxiety, reported that 3 of the 12 studies did find a benefit; however, these trials had smaller samples and there were no shared characteristics among them in terms of the strain or dose of microorganisms used. Despite the lackluster findings related to anxiety, probiotics are able to ease gut symptoms in some individuals living with IBS.73