# Multicomponent approach and IBS



## eric (Jul 8, 1999)

Expert Dialogue The Combination of Medical Treatment Plus Multicomponent Behavioral Therapy is Superior to Medical Treatment Alone in the Therapy of Irritable Bowel Syndrome Heymann-Monnikes I, Arnold R, Florin I, Herda C, Melfsen S, Monnikes H. Amer J Gastro 95:981-994, 2000. Study design: This is a study that compares medical and psychological treatment of IBS. 12 patients were allocated to each group: medical and psychological treatment vs medical treatment alone. Medical treatment was the usual gastroenterological advice in regards to diet and life-style as well as medications. These included antispasmodics, analgesics, anti-diarrheal drugs, pro-motility drugs, laxatives and some low dose anti-depressives. Patients were seen every 2 weeks over a 10 week period. Multicomponent treatment included informational session about IBS, discussion of the patient's model of their illness, progressive muscle relaxation, the following cognitive/behavioral therapy: cognitive coping strategies, problem-solving and assertiveness and social skills training. This treatment was given weekly over the same 10 week period. Measures: IBS symptoms were scored with a daily diary that included 13 GI symptoms. Psychological tests included measures of depression, anxiety, GI quality of life, irrational beliefs and feelings of control related to illness. In addition, response to inflation of a rectal balloon was measured. This was done both for sensation to mild inflation and feeling of pain to greater inflation. Results: Pre-treatment, there was no difference in test results between one group and the other. After treatment, there was no improvement in GI symptoms in the medically treated group while combined therapy resulted in significant improvement. This change was maintained when subjects were tested 3 and 6 months later. In addition, psychological testing showed significant improvement in the multicomponent group in terms of overall well-being, quality of life and sense of control of their health. None of these were improved in the medically treated group. Interestingly, the improvement in GI and psychological status occurred despite the finding that there was no improvement in rectal sensitivity or rectal pain with balloon distension. Dialog: A model of illness Dr. Mary-Joan Gerson: I'm very impressed with this study, for the following reasons. First of all it incorporates many features of our work, i.e. patient education, progressive muscle relation, coping strategies. In particular, patients are active partners in this methodology and each individual "model" of IBS was obtained. This approach is central to our own work but I wonder how often you think gastroenterologists inquire about patient's models. If not, why not? Dr. Charles Gerson: By model, do you mean the patient's description of how the illness effects their life? or the kind of symptoms that they have? Clearly, physicians don't think in terms of individual models. In general, gastroenterologists think of an illness in terms of symptoms that fit their definition of that illness. They feel more in control that way. Dr. Mary-Joan Gerson: By model I mean how each individual with IBS thinks about the relationship of stress and symptoms, and what kinds of stress or psychological events cause symptom outbreaks. Contact between treatment professionals Dr. Mary-Joan Gerson: I think one omission in the report--and it's a crucial one--is a description of the link between the medical and psychological treatments. Did the physician speak to the psychotherapist? How often? Do you think this pattern of conversation is essential or not? Dr. Charles Gerson: I think it is essential. With the psychologist's input, the gastroenterologist would be able to relate to the patient more effectively. This would help whatever treatment advice was given. I don't know that there has to be frequent contact; a few conversations might be adequate. Would speaking to the gastroenterologist help you? Dr. Mary-Joan Gerson: I find it very helpful to get the physician's assessment, i.e. are there unusual aspects of the IBS, how severe the medical assessment is, etc. I feel this gives me a grounding, frees up my psychological focus. How symptoms are judged What do you think of the IBS symptom rating score used here, that is many symptoms rather than a focus on the most dominant ones? Dr. Charles Gerson: Most of the symptoms in the rating score had a large overlap with other conditions. The experts who established the Rome criteria feel that the most reliable symptoms for the diagnosis of IBS are abdominal pain or discomfort, and an altered bowel pattern. That's what we're using in our study. Why people feel better Dr. Mary-Joan Gerson: Of course as a psychologist, I'm struck with the significant changes in well-being, experience of illness in THE ABSENCE of a change in perception of sensation, physiologically measured. Does this surprise you? How does it make you feel about standard treatment? Do you think the issue is that "sensation" rather than "pain" was measured? Dr. Charles Gerson: I was surprised that rectal sensitivity was not improved in the IBS patients. It makes me feel that psychological changes are probably more important than colonic changes in the treatment of IBS. I still feel that some standard GI treatment can be helpful. The results certainly underline the importance of psychological as well as gastroenterological treatment. Why there was no change in rectal sensitivity is unclear. It's not that sensation alone was measured because stimulation to pain was also recorded. The importance of including a psychological component Dr. Mary-Joan Gerson: A possible limitation of its applicability of these results is the amount of time devoted to the multicomponent approach, that is 10 sessions of one hour each. However, even though some patients will not commit themselves to a treatment of this length, the effectiveness indicated statistically argues for it. Overall, what this study demonstrates is that including psychological treatment, specifically designed for IBS, resulted in a reduction in symptomatology-whereas standard medical treatment, including drug treatment, did not. I think it's crucial for gastroenterologists to develop relationships with mental health professionals so that collaboration on patient care can be expanded.------------------ http://www.ibshealth.com/ www.ibsaudioprogram.com


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## JeanG (Oct 20, 1999)

Fantastic article, Eric. I also believe in a well rounded approach. It would be good to have both a GI and a psychotherapist working together on IBS.I like the dialog between the 2 doctors.Thanks again.







JeanG


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