Psychological approach to managing irritable bowel syndrome
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39199.679236.AE (Published 24 May 2007) Cite this as: BMJ 2007;334:1105
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I.B.S. is considered as a brain-gut dysfunctional syndrome by
hypnotherapists and several studies have impressively documented the value
of hypnotherapy for this condition. Gastrointestinal conditions seem to be
stress –related illnesses. These conditions are associated with the
possible involvement of several other emotional factors such as repressed
hostility and anger that may be responsive to hypnotherapy 1. Whorwell’s
study group noticed long term (mean 18months) follow up response rates on
50 patients with 95% success with classical cases, 43% with atypical
cases, and 60% with cases exhibiting significant psychopathology 2. They
also found that patients over age 50 responded poorly (25% success), but
patients below the age of 50 with classical irritable bowel syndrome were
100% successful.
Even though it is not clear whether IBS is caused by stress, it is certain
this condition is worsened by stress. The mechanism of the working of gut-
directed hypnotherapy is enigmatic but it may change the way the brain
modulates gut activity: under hypnosis gut sensitivity is reduced.
References
1.Walker, B.B. (1983) Treating stomach disorders can we reinstate
regulatory processes? In R. Hozl & W.E. Whitehead (Eds),
Psychopathology of the Gastrointestinal Tract: Experimental & Clinical
Applications. New York; plenum, pp209-233
2.Whrwell, P.J., Prior, A., & Faragher, E.B. (1984) Controlled
trial of hypnotherapy in the treatment of service refractory irritable
bowel syndrome. Lancet, 2, 1232-1233
Competing interests:
None declared
Competing interests: No competing interests
Thank you to Dr Hayee and Dr Forgacs for pointing out that it is
actually more therapeutically helpful to patients to quickly make a
POSITIVE diagnosis of IBS and minimize un-needed testing. While some
physicians may see diagnostic testing as a way to avoid “missing
something”, research actually demonstrates that among patients meeting
criteria for IBS who do not have alarm symptoms, the risk of other
underlying pathology is very low. Specifically, a Meta-analysis of 6
studies found that the prevalence of other diseases among patients meeting
IBS criteria was: Colitis/inflammatory bowel disease = 0.5% - 1.0%,
Colorectal cancer = 0% - 0.5%, Celiac disease = 4.7%, Gastrointestinal
infection = 0% - 1.7%, Thyroid dysfunction = 6%, Lactose malabsorption =
22% - 26%. Furthermore, endoscopy, ultrasound, and barium studies only
detected organic disease in approximately 1% of patients, CBC and
chemistries were unhelpful. (1) It is still important, however, to
remember that patients with red flags should have a more thorough
diagnostic evaluation: weight loss, evidence of bleeding, signs of
infection, those older than 50 years at the onset of symptoms.
(1) Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests
in irritable bowel syndrome patients: a systematic review. Am J
Gastroenterol. 2002 Nov;97(11):2812-9.
Competing interests:
None declared
Competing interests: No competing interests
An RCT (Guthrie, 1993, BJPsych) showed the efficacy of Interpersonal
Therapy (psychodynamic, based on Hobson's model - not the IPT of Weissman)
was effective in women with Irritable Bowel Syndrome. This needs to be
mentioned alongside CBT.
Competing interests:
My specialty is psychodynamic psychotherapy
Competing interests: No competing interests
From my daily practise in managing patients with IBS, I feel that
even patients with constipation-predominant IBS benefit from TADs as
patients with diarrhea-predominant IBS,keeping in mind that the mechanism
of action is raising the pain trehold or the teshold for sensing symptoms.
Thanks.
Competing interests:
None declared
Competing interests: No competing interests
Short-term Psychodynamic Psychotherapies for IBS
To the Editor:
I wish to thank Drs Hayee and Forgacs for their review of treatment
of IBS and to add information about some recent developments, assessment
methods and treatment alternatives for this condition.
First, the authors called the method Guthrie et al studied “Cognitive
Behavioral Therapy (CBT)”. In fact it is a variety of short term
psychodynamic/ interpersonal therapy with different theory, technique and
objectives than CBT.
Short-term Psychodynamic Psychotherapies (STPP) have been shown
efficacious in treating IBS now in randomized controlled trials including
one for Refractory IBS (1) and one for Severe IBS (2). The technique has
also been shown efficacious in reducing somatic symptoms in both short and
long-term follow-up in a recent Cochrane review. (3). A current review
(Abbass, Kisely and Kroenke, in preparation) has found over 20 studies of
STPP for a broad range of somatic conditions including IBS, dyspepsia,
ulcer disease, movement disorders, dermatitis, pelvic pain, chronic pain,
headaches, rheumatoid disease, coronary heart disease and other common
conditions. These cost-effective and non-toxic treatments need to be
covered in reviews such as this and given more attention in mainstream
medical literature including the BMJ.
A further issue is that some forms of STPP have built in methods to
directly diagnose emotional factors and their relative contribution to
symptoms such as IBS. (4) Thus, it is possible to directly diagnose these
factors versus to have to speculate about them or only to diagnose by the
assumptive “rule out” method. Since these interview methods exist,
Medicine is behooved to update itself about these relatively non-invasive
diagnostic techniques which can save both the patient and the system undue
suffering.
Sincerely Yours,
Allan Abbass
References:
1. Guthrie, E., Creed, F., Dawson, D., & Tomenson, B. (1993). A
randomised controlled trial of psychotherapy in patients with refractory
irritable bowel syndrome. British Journal of Psychiatry, 163, 315-321.
2. Creed F L F, Guthrie E, Palmer S, Ratcliffe J, Read N, Rigby C, et
al. The Cost Effectiveness of Psychotherapy and Paroxetine for Severe
Irritable Bowel Syndrome. Gastroenterology. 2003;124(124):303-317,
3. Abbass AA, Henderson J, Kisely S., Hancock JT. Short-term
psychodynamic psychotherapies for common mental disorders. Cochrane
Database Syst Rev. 2006; Oct 18;(4):CD004687
4. Abbass A. Somatization Diagnosing it sooner through emotion-
focused interviewing. Journal of Family Practice. 2005;54 (3) 215-24.
Competing interests:
None declared
Competing interests: No competing interests