# Psychosocial Factors in IBS:



## eric (Jul 8, 1999)

with permission"http://www.med.unc.edu/ibs The UNC Center for Functional GI& Motility DisordersPsychosocial Factors in IBS:Toward a More Comprehensive Understandingand Approach to TreatmentYehuda Ringel, MD, Clinical Assistant Professor of Medicine, Division Digestive DiseasesUniversity of North Carolina at Chapel HillDouglas A. Drossman, MD, Co-director, UNC Center for Functional GI & Motility Disorders,University of North Carolina at Chapel HillEdited by Donna Swantkowski, M.Ed., Coordinator, UNC Center for Functional GI & MotilityDisorders, University of North Carolina at Chapel HillThe treatment of functional GI disorders must include not only traditional physicalclinical care but also an assessment of and focus on the psychological issues that mayrelate to these disorders. Studies at DDW 2003 have looked at the following aspects.THE RELEVANCE OF PSYCHOLOGICAL ISSUESAlthough most patients with IBS do not meet criteria for psychological disorders,considerably higher rates of IBS are found in patients with psychiatric diagnosis.However, it is not clear whether psychiatric disorders precede a diagnosis of IBS or is aconsequence of it. Dr. Stuart C. Howell and colleagues at the University of Sydneyperformed a study of Australian subjects for their first 26 years of life to determine theconnection between psychiatric disorders and IBS. By age, 16.7% met the Manningcriteria for IBS. IBS was not found to be more common among individuals with 26chronic psychiatric disorders such as depression and anxiety. The study concluded that inyoung adults IBS is related to personality but not to a history of psychiatric disorder.There are, however, some limitations to consider. The study followed 869 subjects, butsince only 145 of those met the IBS criteria, the actual number of patients that could bestudied was relatively small. This could lead to findings that lack statistical power. IBSwas defined categorically and from a population database, where subjects are more likelyto have a milder illness. It is probable that psychiatric disorder would be found moreoften in those with more severe symptoms and a higher usage of health care. In addition,other psychological factors such as social support and coping style were not studied.POSSIBLE MECHANISMSSeveral studies at DDW offered insights on possible mechanisms by which psychologicaldistress may affect patients' illness and behavior. Britta Dikhaus and colleagues, fromUCLA conducted a study that looked at the effect of auditory induced psychologicalstress on sensitivity and emotional responses to rectal balloon distension in theesophagus. The study tested IBS patients whose predominant symptom is diarrhea as wellas normal individuals who do not have IBS. In the IBS group, relatively to controls, theinduced psychological stress was associated with increased sensitivity and a strongerhttp://www.med.unc.edu/ibs The UNC Center for Functional GI& Motility Disordersemotional response. In the control group of normal subjects, this association was notobserved.In another study, Lloyd J. Gregory from the United Kingdom looked at changes in brainactivation in response to esophageal distension when given either of two tasks: a) a visual(distracting) task and







focusing attention to the esophageal stimulus. There was greaterbrain activation when subjects were asked to concentrate on the esophageal stimulusrather when they did the visual task. The study concluded that conscious selectiveattention to the esophagus during esophageal stimulation results in more brain activationthan when the esophageal stimulus is present but the person is distracted.The effect of psychological factors on IBS sufferers (on patient status, illness severity,and outcome of their disorder) provides the rationalization for using treatments directedtowards modifying attention to gastrointestinal sensations and changing the way they areinterpreted, as occurs in cognitive behavior therapy.PSYCHOTROPIC DRUG TREATMENTThe effectiveness of antidepressant treatment in IBS patients has recently been reported.Antidepressants are also frequently used for a variety of other functional GI symptomsand/syndromes. A meta-analysis by Dr. Ray E. Clouse from the University ofWashington, St. Louis has shown a significant beneficial effect of antidepressants for thefollowing functional gastrointestinal disorders: IBS, functional esophageal symptoms,functional dyspepsia, and abdominal pain.The odds ratio (the percentage of people on active drug who get better divided by thepercent on placebo) benefit exceeds 4 when compared with placebo. Nevertheless,comparative, controlled studies between the different antidepressant classes are stillmissing.PSYCHOLOGICAL TREATMENTSSeveral psychological treatment interventions have been suggested for the treatment ofIBS. These include active psychotherapeutic treatments (Cognitive Behavioral Therapy,Dynamic or interpersonal therapy) as well as more passive treatments (hypnosis orProgressive Muscle Relaxation). Cognitive Behavioral Therapy (CBT) involves thepatient working with a therapist to address specific concerns and perceptions about theirfunctional gastrointestinal symptoms. These are then modified in ways that lead tochanges in cognitive appraisal of stress, which in turn impacts, the patient's bowelsymptoms.Phillip M. Boyce et al reported the results of a study that compared the benefit of CBT,Relaxation Therapy, and Routine Medical Care in IBS patients. A significantimprovement in The Bowel Symptoms Severity Scale, Hospital Anxiety, and SF-36Physical Scores were found at the end of eight weeks. Also, additional improvementoccurred at 10 months of follow up with no treatment. Interestingly there were nodifferences between the three treatment groups, meaning all three were equally effective.The investigators concluded that routine medical care, with an emphasis on education andhttp://www.med.unc.edu/ibs The UNC Center for Functional GI& Motility Disordersreassurance, could be as effective as CBT and relaxation in reducing symptoms andimproving quality of life. This conclusion should be regarded with caution since theseresults are not consistent with several recently published papers showing a beneficialeffect of CBT in patients with IBS. The discrepancies between studies might be related tothe different patient populations with regard to their illness severity or to a failure of theparticular therapy done in this study to be effective. No process measures were reportedto determine if there was indeed evidence that the CBT Treatment to more effectivethinking. Additional studies with larger samples of patients selected by their severity, andusing standardized CBT treatments along with measures to assess CBT effect are needed.Dr. Francis H. Creed from the University of Manchester, in the United Kingdom,conducted a study to explore the cost-effectiveness of combining psychotherapy andSSRI antidepressants treatment for severe irritable bowel syndrome. Patients wererandomized into one of three treatments: a) 7 sessions of individual psychotherapy, 20mgs daily of paroxetine, c) or routine medical care. After one year, psychotherapy andantidepressant were superior to routine care in reducing disability in IBS patients.However, there were no differences, among the groups, in terms of GI symptomsthemselves after 3 month or one year follow-ups.In Creed's study, health related quality of life improved during treatment more forpsychological and SSRI antidepressants groups than for the routine care group. Allgroups showed improvement in quality of life at the one-year follow-up. Finally, healthcare costs were similar for all groups by 3 months follow-up, but by the end of one year,the psychotherapy group consumed significantly fewer health costs than the other twogroups. This suggests that patients continue to benefit with psychotherapy over time, andthis is related to reduced health care costs.Hypnotherapy is another non-pharmacological treatment for IBS. Peter Whorwell's groupat the University of South Manchester have shown the efficacy of hypnotherapy inimproving symptoms, quality of life, and more recently the long term treatments offunctional dyspepsia. The results of a randomized controlled study, by Emma L. Calvert,in which patients either received hypnotherapy, conventional treatment with ranitidine150mg twice daily, or supportive therapy for 16 weeks showed that the improvements infunctional dyspepsia were similar between the 3 groups. However, long-termhypnotherapy was superior to other treatments in improving the quality of life and inreducing the need for medication. Another study presented by Giuseppe Chiarioni fromVerona, Italy showed increased gastric emptying in response to hypnotic relaxation withgut-oriented suggestions in healthy controls and patients with functional dyspepsia.Again the effect was greater in patients who received hypnotherapy than with Cisapride.The efficacy of hypnotherapy warrants additional studies.The variety of studies presented at DDW 2003 reflects the continuo us change in the wayfunctional disorders are conceptualized and the growing acceptance and understanding ofthese disorders. Continued researches in this area will contribute to the improvement ofour care for patients with functional disorders."


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