Evidence-Based Reviews

Irritable bowel syndrome: Psychotherapy can improve GI symptoms and emotional health

Current Psychiatry. 2002 September;1(9):47-52

Medical treatment alone has proven disappointing, but psychotherapeutic approaches are showing promise.

References

1. Sandler R. Epidemiology of irritable bowel syndrome in the United States. Gastroenterology 1990;99:409-15.

2. Leserman J, Drossman DA, Li Z, et al. Sexual and physical abuse history in gastroenterology practice: how types of abuse impact health status. Psychosom Med 1996;58:4-15.

3. Klein KB. Controlled treatment trials in the irritable bowel syndrome: a critique. Gastroenterology 1988;95:232-41.

4. Jailwala J, Imperiale TF, Kroenke K. Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized, controlled trials. Ann Intern Med 2000;133:136-47.

5. Svedlund J, Sjodin I, Ottosson JO, et al. Controlled study of psychotherapy in irritable bowel syndrome. Lancet 1983;ii:589-92.

6. Guthrie EA, Creed FH, Dawson D, et al. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology 1991;100:450-7.

7. Guthrie EA, Creed FH, Dawson D, et al. A randomized controlled trial of psychotherapy in patients with refractory irritable bowel syndrome. Br J Psychiatry 1993;163:315-21.

8. Blanchard EB, Schwartz SP. Adaptation of a multi-component treatment program for irritable bowel syndrome to a small group format. Biofeedback Self-Regulation 1987;12:63-9.

9. Blanchard EB, Scharff L, Payne A, et al. Prediction of outcome from cognitive-behavioral treatment of irritable bowel syndrome. Behav Res Ther 1992;30:647-50.

10. Greene B, Blanchard EB. Cognitive therapy for irritable bowel syndrome. J Consult Clin Psychol 1994;62(3):576-82.

11. Van Dulmen AM, Fennis JFM, Bleijenberg G. Cognitive-behavioral group therapy for irritable bowel syndrome: effects and long-term follow-up. Psychosom Med 1996;58:508-14.

12. Payne A, Blanchard EB. A controlled comparison of cognitive therapy and self-help support groups in the treatment of irritable bowel syndrome. J Consult Clin Psychol 1995;63(5):779-86.

13. Wise TN, Cooper JN, Ahmed S. The efficacy of group therapy for patients with irritable bowel syndrome. Psychosomatics 1982;23:465-9.

14. Toner BB, Segal ZV, Emmott S, et al. Cognitive-behavioral group therapy for patients with irritable bowel syndrome. Int J Group Psychotherapy 1998;48(2):215-43.

15. Whorwell PJ, Prior A, Faragher EB. Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet 1984;2(8414):1232-43.

16. Prior A, Colgan SM, Whorwell PJ. Changes in rectal sensitivity after hypnotherapy in patients with irritable bowel syndrome. Gut 1990;31:896-8.

17. Whorwell PJ, Houghton LA, Taylor EE, et al. Physiological effects of emotion: assessment via hypnosis. Lancet 1992;340:69-72.

18. Houghton LA, Heyman DJ, Whorwell PJ. Symptomatology, quality of life and economic features of irritable bowel syndrome: the effect of hypnotherapy. Aliment Pharmacol Ther 1996;10(1):91-5.

19. Galovski TE, Blanchard EB. The treatment of irritable bowel syndrome with hypnotherapy. Appl Psychophysiol Biofeedback 1998;23(4):219-32.

20. Vidakovic-Vukic M. Hypnotherapy in the treatment of irritable bowel syndrome: methods and results in Amsterdam. Scandinavian University Press 1999;34(suppl 230):49-51.

21. Bassotti G, Whitehead WE. Biofeedback as a treatment approach to gastrointestinal tract disorders. Am J Gastroenterol 1994;89(2):158-64.

22. Jackson JL, O’Malley PG, et al. Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. Am J Med 2000;108:65-72.

23. Heymann-Mönnikes I, Arnold R, Florin I, et al. The combination of medical treatment plus multicomponent behavioral therapy is superior to medical treatment alone in the therapy of irritable bowel syndrome. Am J Gastroenterol 2000;95:981-94.

A growing body of evidence suggests that psychiatrists have much to offer patients with severe irritable bowel syndrome (IBS). Behavioral and psychotherapeutic approaches are showing promise in relieving both GI and mood disturbances.

Treating patients with IBS with medications designed to influence only gut function can be frustrating. Those with refractory symptoms may be extremely sensitive to drug side effects, and they often report that medical management worsens or does not improve their symptoms. They experiment with alternative medicines and wander from physician to physician in a disappointing search for a “cure.”

Let’s look at evidence on the efficacy of individual and group behavioral therapies, hypnotherapy, biofeedback, and combination medical and behavioral treatment.

Psychotherapeutic approaches

IBS is a common gastrointestinal disorder that is characterized by abdominal discomfort and changes in bowel habits (Boxes 1 and 2). Patients with severe IBS symptoms often bring significant psychological impairment and psychosocial trauma to clinical encounters.^1,2 They respond poorly to standard medical management, and evidence supporting the efficacy of medical treatments for IBS remains weak.^3,4

Box 1

WHAT IS IRRITABLE BOWEL SYNDROME?

Irritable bowel syndrome (IBS) is the most common disorder seen in gastrointestinal practice, representing more than 40% of all visits to gastroenterologists. Complaints of IBS also account for approximately 23% of office visits to primary care physicians.¹

Key symptoms of this functional disorder are a pattern of lower abdominal discomfort and bloating accompanied by variable degrees of altered stool pattern—constipation, diarrhea, or intermittent constipation and diarrhea. IBS is most common in young patients, with onset rarely diagnosed after age 45. Its incidence is equal in men and women, but women are more likely to seek medical care for IBS symptoms.

The cause of IBS is unclear. Recent research suggests that changes in serotonin metabolism cause a pattern of visceral hypersensitivity and an altered sensation of pain. IBS is not a psychiatric disorder, but it can be worsened by comorbid psychopathology, particularly mood and anxiety disorders. Although patients tend to have either diarrhea-predominant or constipation-predominant IBS, the pathophysiology of both patterns seems similar.

In 1983, the first controlled trial of psychodynamic psychotherapy for IBS showed dramatic reductions in symptoms.⁵ A subsequent series of high-quality articles in the early 1990s also showed that interpersonal psychotherapy (with greater interaction between therapist and patient) could significantly decrease IBS symptoms.

Persistent improvement. In one randomized controlled trial,⁶ 102 patients with IBS received either standard medical treatment or 10 hours of dynamically oriented individual psychotherapy in combination with standard medical treatment. After 3 months, patients who received psychotherapy showed significantly greater improvement in somatic symptoms and emotional well-being, compared with those who received medical treatment only.

Interestingly, this difference persisted 1 year after the study ended. GI symptoms and the emotional well-being of patients who received combination therapy continued to improve, whereas the physical and emotional status of those who received only standard medical treatment deteriorated.

In a second study,⁷ 101 patients with severe IBS symptoms continued to receive medical treatment but were randomly divided into two groups:

Study subjects received 8 hours of dynamically oriented psychotherapy.
Control patients met with a psychiatrist who engaged in “supportive listening” but delivered no psychotherapy. This strategy was adopted to control for the effect of the psychiatrist’s presence.

Assessments included patients’ self-reports of symptoms, ratings of GI symptoms by the treating gastroenterologists, and measures of depression, anxiety, and health care utilization. Patients who received psychotherapy reported significant improvements in bowel symptoms (e.g., diarrhea, constipation, bloating, and abdominal pain). Likewise, the gastroenterologist who rated patients’ GI symptoms felt that those who received psychotherapy improved significantly across the entire spectrum of GI symptoms. The improvements were maintained at 1-year follow-up.

By comparison, the control patients reported worsening symptoms, as did subjects who dropped out. Patients who received psychotherapy also made significantly fewer outpatient visits to gastroenterologists, compared with controls (p<0.001).

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) is emerging as a major psychotherapeutic tool for treating mood disorders, anxiety disorders, and somatic syndromes associated with psychosocial distress. CBT also is showing promise for patients with moderate to severe IBS and those with IBS and concomitant anxiety or mood disorders. Studies consistently show that CBT is superior to standard medical management or the use of support groups or other behavioral treatments alone.

Reduced symptoms. In an early trial of CBT, 17 patients with IBS experienced significantly less abdominal pain and diarrhea after participating in a program of progressive relaxation, education about bowel functioning, use of thermal biofeedback, and stress coping techniques based on CBT. Overall, 64% of the patients improved.⁸