Irritable bowel syndrome: Psychotherapy can improve GI symptoms and emotional health
Medical treatment alone has proven disappointing, but psychotherapeutic approaches are showing promise.
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.
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
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 (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
The same investigators then assigned 90 patients to 12 sessions of CBT, given over 8 weeks with or without meditation and biofeedback. Patients with axis I psychiatric diagnoses tended to respond poorly to CBT. The authors concluded that a careful pretreatment psychological workup is important to identify patients with IBS who would benefit most from CBT.9
As a follow-up, these investigators randomly assigned 20 patients to intensive individualized CBT (10 sessions over 8 weeks) or 8 weeks of daily GI symptom monitoring. Patients who received CBT had significantly fewer GI symptoms than did the symptom-monitoring group (p = 0.005). With CBT, 80% improved clinically, compared with only 10% in the control group. Improvements in the CBT group persisted at 3 months’ follow-up. Improved GI symptoms also were correlated with increased positive thoughts and reduced negative automatic thoughts (i.e., negative self-image).10
DIAGNOSTIC CRITERIA* FOR IBS
In the preceding 12 months, the patient has experienced at least 12 weeks or more (need not be consecutive) of abdominal discomfort or pain that has:
Two out of three features
- relieved with defecation, and/or
- onset associated with a change in frequency or stool, and/or
- onset associated with a change in form (appearance) of stool
Symptoms that cumulatively support the diagnosis
- Abnormal stool frequency (for research purposes, “abnormal” may be defined as >3 bowel movements per day and <3 bowel movements per week);
- abnormal stool form (lumpy/hard or loose/watery stool)
- abnormal stool passage (straining, urgency, or feeling of incomplete evacuation)
- passage of mucus
- bloating or abdominal distension.
* In the absence of structural or metabolic abnormalities to explain the symptoms
Source: Drossman DA, Corazziari E, Talley NJ, et al. Rome II: The functional gastrointestinal disorders (2nd ed). McLean, VA: Degnon Associates, 2000.
Group therapy. In a study of group rather than individualized CBT, 45 patients with severe IBS symptoms were randomly assigned to either a group CBT module (n = 25) or a waiting list control group (n = 20). Patients received eight 2-hour group CBT sessions over 3 months, then were followed an average of 2.25 years. Their abdominal pain, number of successful coping behavioral strategies, and avoidance of negative situations improved significantly—compared with the waiting list controls—and persisted during follow-up. The authors concluded that group CBT is effective for alleviating IBS symptoms and improving patients’ coping strategies.11
CBT vs. support groups. In a study comparing the effectiveness of CBT and an IBS self-help support group, 34 patients were randomly assigned to:
- individualized CBT (study group)
- a self-help support group
- or a symptom-monitoring waiting list (control group).
Each group was followed for 8 weeks. GI symptoms were reduced significantly in patients who received individualized CBT, compared with the support group or controls. Anxiety and depression in the CBT group also remained significantly improved 3 months later, compared with both other groups.12
Group psychotherapy for IBS treatment can be more cost-effective than individual therapy, but its success depends on whether patients accept a group format. Data on the use of group psychotherapeutic approaches are largely favorable.
As described previously, one study demonstrated that group CBT reduced abdominal pain and diarrhea and improved symptoms overall.11 In another study, 20 patients with refractory IBS underwent 6 weeks of group behavioral and didactic psychotherapy. GI symptoms, dysphoria, and psychological distress improved significantly in all patients, and their interpersonal sensitivity and hostility were reduced. These improvements persisted 6 months later. 12
A recent review suggests that cognitive-behavioral group psychotherapy may be highly effective in patients with IBS. These authors concluded that CBT can improve patients’ mood and other emotional symptoms, reduce their pain, and improve well-being and coping ability.14
Researchers in Manchester, UK, have shown excellent results with hypnotherapy for patients with severe refractory IBS. Although their data seem to have established the ability of hypnotherapy to improve the GI and non-GI symptoms of IBS, corroborating evidence is needed from other centers. In this regard, some preliminary evidence is emerging.
Manchester group. In the first trial by the Manchester group, 30 patients received seven half-hour sessions of hypnotherapy (study group) or supportive psychotherapy and placebo (control group). Patients who received hypnotherapy also were given a tape for home autohypnosis after the third session.
Patients who received hypnotherapy improved dramatically in all GI symptoms— including abdominal pain, bloating, and bowel habits—and in their sense of well-being. This effect persisted 3 months later. The control patients’ abdominal pain, bloating, and well-being improved somewhat, but their bowel habits did not improve.15
The same investigators then studied 30 patients with IBS to assess the effect of hypnotherapy on rectal physiology. Fifteen patients received hypnotherapy, and 15 received relaxation exercises. Rectal sensitivity was measured using anorectal manometry at the start and finish of the intervention.
For patients with diarrhea-predominant IBS, rectal sensitivity was significantly reduced during hypnosis and after the full course of hypnotherapy, compared with controls (p<0.05). In patients with constipation-predominant IBS, a trend towards normalized rectal sensitivity did not reach statistical significance. The investigators concluded that symptomatic improvement of IBS after hypnotherapy may be related to changes in visceral sensitivity of the colon.16
These investigators later studied changes in distal colonic motility in 18 patients undergoing hypnotherapy for IBS. As the patients’ hypnotically induced anger or excitement increased, colonic motility decreased significantly (p<0.01) The investigators concluded that hypnosis may be a useful tool to investigate the effects of emotion on physiologic function.17
Using more contemporary outcome measures and diagnostic criteria, these investigators later showed that hypnotherapy significantly improved:
- IBS symptoms (abdominal pain and bloating, bowel habit, nausea, flatulence, urinary symptoms, lethargy, backache, and dyspareunia)
- quality of life (psychological and physical well-being, mood, locus of control, and work attitude).
Patients treated with hypnosis also took less time away from work (p = 0.02) and visited their physicians less often (p = 0.056), compared with controls. 18
Other hypnosis studies. In the United States, another group randomly assigned 12 patients to gut-directed hypnotherapy or symptom monitoring. Subjects were matched by concurrent psychiatric diagnosis, susceptibility to hypnosis, and demographic features.
In findings similar to those of the Manchester group, primary IBS symptoms (abdominal pain, constipation, and flatulence) of patients who received hypnotherapy improved more than those of controls (p = 0.016). Anxiety, as measured by the Spielberger State-Trait Anxiety Inventory (STAXI), also decreased significantly. Treatment-induced gains were well-maintained 2 months later. No significant correlation was found between initial sensitivity to hypnosis and subsequent response to hypnotherapy. A positive relationship was seen between the presence of psychiatric diagnoses and overall levels of improvement.
This study suggests that hypnotherapy can be useful for treating IBS and can be easily adapted to different clinical settings and treatment populations. 19 A similar study using gut-directed hypnotherapy found significant improvement in 27 IBS patients treated with short-term hypnosis, and symptom improvement persisted after treatment.20
The role of biofeedback in IBS treatment remains ill-defined. To be considered as a treatment option, biofeedback must meet or exceed the benefits being achieved with psychotherapy, hypnotherapy, and other behavioral approaches.
In gastroenterology, biofeedback has been used mainly to treat constipation and specifically for outlet constipation due to pelvic floor dysfunction. Anorectal probes to measure rectal pressure in the resting state and during defecation can reveal a pattern of pelvic floor dysfunction. Studies have demonstrated up to 67% improvement in constipation symptoms using biofeedback. Use of anorectal biofeedback in adults with IBS also appears promising, but more controlled trials are needed.21