Exposure and mindfulness based therapy for irritable bowel syndrome--an open pilot study

Managing pain in irritable bowel syndrome: current perspectives and best practice

INTRODUCTION

Irritable bowel syndrome (IBS) is characterized by chronic symptoms (>6 months) of abdominal pain in combination with a disturbed bowel habit. There is an association between the intensity of abdominal pain and the need for health care utilization. A bidirectionally disordered gut-brain interaction is central in the pathophysiology of IBS where a number of factors, gastrointestinal and non-gastrointestinal, can contribute to the illness experience. In order to treat abdominal pain in IBS, mapping these factors in a multidimensional clinical profile is helpful.

AREAS COVERED

This review covers basic epidemiology and pathophysiology of abdominal pain in IBS, the diagnostic approach, and a multidimensional treatment model where the management of abdominal pain is in focus.

EXPERT OPINION

A personalized treatment of abdominal pain in IBS is possible in patients who understand the diagnosis, the potential of therapies used, and where a good continuity in the patient-doctor relationship is established.

Effectiveness of Psycho-Religious Sexuality Education upon Anger and Depression of Iranian Female Adolescents: The Relationship of Quality Family Relationships and Birth Order

Sexually active adolescents tend to have a wider range of psychosocial problems, including depression, anger, poor academic achievement, low self-esteem, and substance use. Developing a high-quality and curriculum-based comprehensive sexuality education (CSE) program is of great importance for adolescents following Iranian culture. Due to the lack of such an educational program, the purpose of this study was to investigate the effectiveness of psycho-religious CSE upon anger and depression of Iranian female adolescents, as well as the relationship of quality family relationships and birth order. The research design is quasi-experimental with pre-test and post-test with experimental and control groups. The statistical population of this study comprised all Iranian female adolescents aged 15 to 18 years in Mashhad who participated in this workshop voluntarily. For data collection, the Child and Adolescent Depression Inventory and Spielberger's State-Trait Anger Expression Inventory (STAXI) were used. SPSS 21 software and analysis of variance (ANOVA) and covariance (ANCOVA) were used for data analysis. The results showed that there was a significant difference in the mean difference between depression and anger in the control and experimental groups (p-Value < 0.05). The results also showed a significant relationship between birth order and the quality of family relationships on depression and anger. Psycho-religious-based SE can reduce depression and anger in female students. These findings can be used in planning educational interventions with a psycho-religious-based approach to reducing anger, depressive symptoms and dangerous sexual behaviors among adolescents.

Placebo effects in functional dyspepsia: Causes and implications for clinical trials

Placebo responses to an apparently inactive intervention are of interest from a scientific perspective as they suggest possible mechanism(s) at work beyond the intervention itself. They are also of interest from a clinical trials perspective since high rates of placebo response limit the potential to demonstrate worthwhile efficacy of a new intervention. This mini-review was motivated by the work of Bosman and colleagues(Neurogastroenterol Motil, 2022, and e14474) that is published in this issue of the journal in which they report on a systematic review and meta-analysis of placebo response in functional dyspepsia clinical trials. The review sets the scene for their work by putting it in the context of other disorders of brain-gut interaction and extra-gastrointestinal disorders. The review canvasses potential mechanisms of placebo response.

Exposure based cognitive behavioral group therapy for IBS at a gastroenterological clinic - a clinical effectiveness study

BACKGROUND

Patients with irritable bowel syndrome (IBS) may benefit from psychological treatment when diet changes and medications do not sufficiently reduce symptoms. Our research team has developed an exposure based cognitive behavioral therapy protocol (ECBT), which has been shown to be effective in several randomized controlled trials.

AIM

To investigate the effectiveness of ECBT in clinical routine care at a gastroenterological clinic in Stockholm and to find predictors for treatment outcome.

METHOD

A ten session ECBT based on our protocol was given face to face by licensed psychologists in groups of 4-6 patients. A total of 129 patients provided information regarding IBS symptoms, quality of life, gastrointestinal symptom-specific anxiety (GSA), and depression pre and post-treatment. We used linear regression analyses to identify patient characteristics that predicted treatment outcome.

RESULTS

The primary outcome was symptom severity measured with The Gastrointestinal Symptom Rating Scale for IBS (GSRS-IBS). Average pre-and post-treatment GSRS-IBS scores were 49.24 (SD = 11.54) and 37.03 (SD = 10.03), corresponding to a 34.0% reduction in symptom severity (p < .001). Reductions were also found in GSA, 43.9% (p < .001) and depression, 38.6% (p < .001). IBS-related quality of life was on average increased by 68.2% (p < .001). The effect sizes were large and varied between (Cohen's d) 0.95 and 1.84. None of the patients' pre-treatment characteristics predicted outcome.

CONCLUSION

We conclude that ECBT for IBS delivered face-to-face in a group-format is very effective, also in a routine care setting. We did not find any reliable predictors for treatment outcome. The trial was registered at Clinicaltrials.gov with ID: NCT04756414.

Lessons learned developing and testing family-based interoceptive exposure for adolescents with low-weight eating disorders

BACKGROUND

Anorexia nervosa (AN) usually develops in early adolescence and is characterized by high rates of morbidity and mortality. Family-based therapy (FBT) is the leading evidence-based treatment for adolescents with AN, but not all patients experience sufficient improvement. The purpose of this manuscript is to describe the development and subsequent experience with a Family-Based Interoceptive Exposure (FBT-IE) for adolescents with a broader form of low-weight eating disorders.

METHODS

The novel IE-based behavioral intervention is a six-session family-based treatment module designed to directly target and modify disgust by altering the prefrontal regulation of the insula response to aversive stimuli by decreasing visceral sensitivity (e.g., bloating). Each session teaches a new skill regarding tolerating distress to visceral sensations associated with disgust and an in-vivo "IE exercise," in which the family is provided with a meal replacement shake of unknown content and caloric density.

RESULTS

In this novel treatment, the patient learns to tolerate disgust in the context of a challenging food stimulus as a way to increase consumption of restricted foods outside of session.

CONCLUSION

We discuss successes and challenges executing this treatment with patients with low-weight eating disorders and propose future directions for the intervention.

Return on investment of internet delivered exposure therapy for irritable bowel syndrome: a randomized controlled trial

Background

Irritable bowel syndrome (IBS) is a debilitating and costly disorder. Cognitive behavior therapy (CBT) is effective in the treatment of IBS, both when delivered over the internet and in face-to-face settings. CBT consists of different components and little is known about their relative importance. We have in an earlier study showed that inclusion of exposure in the CBT for IBS makes it even more effective. In the present study we wanted to evaluate the economic effects for society of inclusion vs exclusion of exposure in an internet delivered CBT for IBS.

Methods

We used data from a previous study with 309 participants with IBS. Participants were randomized to internet delivered CBT with (ICBT) or without exposure (ICBT-WE). We compared direct and indirect costs at baseline, after treatment, and 6 months after treatment (primary endpoint; 6MFU). Data was also collected on symptom severity and time spent by therapists and participants. The relative Incremental Cost Effectiveness Ratio (ICER) was calculated for the two treatment conditions and the return on investment (ROI).

Results

Results showed that ICBT cost $213.5 (20%) more than ICBT-WE per participant. However, ICBT was associated with larger reductions regarding both costs and symptoms than ICBT-WE at 6MFU. The ICER was − 301.69, meaning that for every point improvement on the Gastrointestinal Symptom Rating Scale—IBS version in ICBT, societal costs would be reduced with approximately $300. At a willingness to pay for a case of clinically significant improvement in IBS symptoms of $0, there was an 84% probability of cost-effectiveness. ROI analysis showed that for every $1 invested in ICBT rather than ICBT-WE, the return would be $5.64 six months after treatment. Analyses of post-treatment data showed a similar pattern although cost-savings were smaller.

Conclusions

Including exposure in Cognitive Behavior Treatment for IBS is more cost-effective from a societal perspective than not including it, even though it may demand more therapist and patient time in the short term.

Trial registration

This study is reported in accordance with the CONSORT statement for non-pharmacological trials [1]. Clinicaltrials.gov registration ID: NCT01529567 (14/02/2013).

Health-Related Quality of Life in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

Irritable bowel syndrome (IBS) affects up to 20% of the global population and is associated with impaired health-related quality of life (HRQoL). This systematic review and meta-analysis aimed to investigate differences in HRQoL of those with IBS compared with healthy controls and to examine whether HRQoL improves following psychological intervention. Online databases were searched for articles from 2002 to 2017. Studies were screened and data extracted according to predetermined criteria. A total of 4,154 citations were identified from which 36 were eligible for inclusion. Eight studies compared HRQoL of those with IBS (n = 822) with that of healthy individuals (n = 3,809). Those with IBS suffered significant impairment across all HRQoL domains compared with healthy individuals, with the majority of effects (Cohen's d) being moderate to large. Twenty-eight studies investigated HRQoL in IBS following psychological intervention (n = 1,308) relative to controls (n = 1,006). All HRQoL domains improved with large effects following treatment; however, maintenance of these effects was inconsistent. Those with IBS experience poorer HRQoL than the wider community; nevertheless, psychological interventions are associated with improved HRQoL across all domains. High-quality studies are needed to better inform gastroenterological nurses of which interventions are most efficacious in alleviating the burden of IBS, and which IBS subpopulations would benefit.

Mechanisms of Food-Induced Symptom Induction and Dietary Management in Functional Dyspepsia

Functional dyspepsia (FD) is a common disorder of gut-brain interaction, characterised by upper gastrointestinal symptom profiles that differentiate FD from the irritable bowel syndrome (IBS), although the two conditions often co-exist. Despite food and eating being implicated in FD symptom induction, evidence-based guidance for dietetic management of FD is limited. The aim of this narrative review is to collate the possible mechanisms for eating-induced and food-related symptoms of FD for stratification of dietetic management. Specific carbohydrates, proteins and fats, or foods high in these macronutrients have all been reported as influencing FD symptom induction, with removal of 'trigger' foods or nutrients shown to alleviate symptoms. Food additives and natural food chemicals have also been implicated, but there is a lack of convincing evidence. Emerging evidence suggests the gastrointestinal microbiota is the primary interface between food and symptom induction in FD, and is therefore a research direction that warrants substantial attention. Objective markers of FD, along with more sensitive and specific dietary assessment tools will contribute to progressing towards evidence-based dietetic management of FD.

The multiple mediating effects of cancer threat appraisal and quality of life on the association between mindfulness and depression for colorectal cancer survivors

OBJECTIVE

This study explored the multiple mediating effects of cancer threat appraisal, functional status, and symptom distress on the association between mindfulness and depression in colorectal cancer (CRC) patients at the transition stage after completing cancer treatments.

METHODS

A total of 90 CRC survivors who received cancer treatments within 3 months participated in this cross-sectional study. The functional status and symptom distress (EORTC-C30 and EORTC CR29), dispositional mindfulness (Five Facet Mindfulness Questionnaire), cancer threat appraisal ( Constructed Meaning Scale), and depressive symptoms (Beck Depression Inventory-II scale) were collected. The mediation and moderation analyses were conducted using the PROCESS macros for SPSS.

RESULTS

Survivors' dispositional mindfulness (γ = -0.49, p < 0.001) and cancer threat appraisal (γ = -0.59, p < 0.001) were significantly associated with depressive symptoms. Simple mediation analysis indicated that cancer threat appraisal mediated the relationship between dispositional mindfulness and depression (β = -0.02, 95% CI = -0.04 to -0.001). The multiple mediated analysis identified the path between dispositional mindfulness and depression via cancer threat appraisal and colorectal symptom distress (β = -0.01, 95% CI = -0.03 to -0.01). In the mediated moderation model, the path between dispositional mindfulness and depression via colorectal function was moderated by cancer threat appraisal (β = -0.02, 95% CI = -0.05 to -0.004).

CONCLUSIONS

The two cognitive mechanisms of reducing CRC survivors' depression are as follows: (1) dispositional mindfulness reducing the appraisal of cancer as a threat and increasing positive perceptions of CRC symptoms and (2) the cancer threat appraisal buffered the impacts of CRC's mindfulness and colorectal function on depressive symptoms. Developing mindfulness with cognitive training is recommended for improving depressive symptoms among CRC patients in the transition period.

What Works in Mindfulness Interventions for Medically Unexplained Symptoms? A Systematic Review

Background/Purpose: Mindfulness-based interventions (MBIs) have been used in medically unexplained symptoms (MUS). This systematic review describes the literature investigating the general effect of MBIs on MUS and identifies the effects of specific MBIs on specific MUS conditions. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines (PRISMA) and the modified Oxford Quality Scoring System (Jadad score) were applied to the review, yielding an initial 1,556 articles. The search engines included PubMed, ScienceDirect, Web of Science, Scopus, EMBASE, and PsychINFO using the search terms: mindfulness, or mediations, or mindful or MBCT or MBSR and medically unexplained symptoms or MUS or Fibromyalgia or FMS. A total of 24 articles were included in the final systematic review. Results/Conclusions: MBIs showed large effects on: symptom severity (d  = 0.82), pain intensity (d  = 0.79), depression (d  = 0.62), and anxiety (d  = 0.67). A manualized MBI that applies the four fundamental elements present in all types of interventions were critical to efficacy. These elements were psycho-education sessions specific to better understand the medical symptoms, the practice of awareness, the nonjudgmental observance of the experience in the moment, and the compassion to ones’ self. The effectiveness of different mindfulness interventions necessitates giving attention to improve the gaps that were identified related to home-based practice monitoring, competency training of mindfulness teachers, and sound psychometric properties to measure the mindfulness practice.

Imagined paralysis alters somatosensory evoked-potentials

Recent studies employing body illusions have shown that multisensory conflict can alter body representations and modulate low-level sensory processing. One defining feature of these body illusions is that they are sensory driven and thus passive on behalf of the participant. Thus, it remained to establish whether explicit alteration of own-body representations modulates low-level sensory processing. We investigated whether tibial nerve somatosensory-evoked potentials were modulated when participants imagined paralysis of their legs and arms. Imagined paralysis of the legs decreased P40 amplitude, but not imagined paralysis of the arms. These results show modulation of early somatosensory processing via explicit, top-down alteration to the internal representation of the body. Interestingly, P40 suppression positively correlated with bodily awareness scores whereas it negatively correlated with body dissociation scores. This suggests that the ability to actively alter own-body representation and its corresponding sensory processing depends upon dispositions to attend to and focus on bodily sensations.

Anxiety Disorders and Medical Comorbidity: Treatment Implications

Anxiety disorders are debilitating psychological disorders characterized by a wide range of cognitive and somatic symptoms. Anxiety sufferers have a higher lifetime prevalence of various medical problems. Chronic medical conditions furthermore increase the likelihood of psychiatric disorders and overall dysfunction. Lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems are disproportionately high in anxiety and panic/fear sufferers. The heightened comorbidity is not surprising as many symptoms of anxiety and panic/fear mimic symptoms of medical conditions. Panic disorder specifically is strongly linked to medical conditions due to its salient somatic symptoms, such as dyspnea, dizziness, numbness, chest pain, and heart palpitations, all of which can signal danger and deterioration for chronic disease sufferers. This chapter identifies shared correlates of medical illness and anxiety disorders and evidence for misinterpretation of symptoms as medically relevant and offers an analysis of implications for treatment of both types of conditions. We will concentrate on medical conditions with high associations for anxiety and panic by aspects of symptomatology, specifically neurological disorders (fibromyalgia, epilepsy, cerebral palsy), diabetes, gastrointestinal illness (irritable bowel syndrome, gastroesophageal reflux disease), and cardiovascular and respiratory illnesses (asthma).

The Efficacy of Acceptance and Commitment Therapy (ACT) Matrix on Depression and Psychological Capital of the Patients with Irritable Bowel Syndrome

BACKGROUND:

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders, worldwide. Psychological disorders are common among patients with IBS.

AIM:

This study aims to investigate the efficacy of acceptance and commitment therapy (ACT) matrix on depression and psychological capital of patients with IBS.

MATERIAL AND METHODS:

In a quasi-experimental study, a total number of 30 patients with IBS were selected using convenience sampling. Those patients who meet the inclusion criteria were randomly assigned to control and experimental groups (15 patients in each group). Data were collected using the Beck Depression Inventory (BDI) and the Psychological Capital Questionnaire (PCQ). The experimental group was subjected to the acceptance and commitment therapy (ACT) amtrix, but the control group do not receive this treatment. Questionnaires were completed before (pre-test) and after (post-test) the intervention by patients in two groups. All patients in two groups responded to the questionnaires and returned them to the researcher. Data were analyzed using chi-square test, independent t-test, analysis of covariance (ANCOVA) and multivariate analysis of covariance (MANCOVA).

RESULTS:

Analyzing the data showed that there were significant differences regarding depression and psychological capital between experimental and control group, before and after the study (p < 0.05).

CONCLUSION:

Using ACT matrix is a useful modality to improve the depression and psychological capital among patients with IBS.

Effect of attention bias modification on event-related potentials in patients with irritable bowel syndrome: A preliminary brain function and psycho-behavioral study

BACKGROUND

Attention bias modification normalizes electroencephalographic abnormalities in alpha and beta power percentages related to attention in patients with irritable bowel syndrome (IBS). Yet, it is unknown whether ABM contributes to the normalization of event-related potentials (ERP) in these patients. We hypothesized that ERP related to attention deficit would be normalized after ABM implementation in individuals with IBS.

METHODS

Thirteen patients with IBS and 10 control subjects completed a 2-month intervention that included five ABM sessions. Each session included 128 trials, resulting in a total of 640 trials during the study period. Event-related potentials were measured at the first and fifth sessions. As per the international 10-20 system for electroencephalographic electrode placement, right parietal P4 was evaluated to measure the attention component of facial expression processing.

KEY RESULTS

A group comparison of P100 latency at P4 revealed that latencies were significantly different between groups in session 1 (IBS vs control, 108 ± 8 vs 97 ± 14; t = -2.51, P = .0203). This difference was absent in session 5 (94 ± 11 vs 93 ± 11, respectively; t = -0.397, P = .6954, r = .09), indicating an effect of ABM in the IBS group.

CONCLUSIONS AND INFERENCES

Attention bias modification may have clinical utility for normalizing brain function and specifically attentional abnormalities in patients with IBS.

Cognitive behavioral therapy for irritable bowel syndrome: the effects on state and trait anxiety and the autonomic nervous system during induced rectal distensions - An uncontrolled trial

BACKGROUND AND AIMS

Irritable bowel syndrome (IBS), is a common multifactorial gastrointestinal disorder linked to disturbances in the microbe gut-brain axis. Cognitive behavioral therapy (CBT), in face-to-face format has showed promising results on IBS and its associated psychological symptoms. The present study explored for the first time if CBT for IBS affects the autonomic nervous system (ANS) during experimentally induced visceral pain and cognitive stress, respectively. The levels of state and trait anxiety, current and perceived stress were also evaluated.

METHODS

In this uncontrolled trial, individual CBT was performed in face-to-face format for 12 weeks in 18 subjects with IBS. Heart rate variability and skin conductance were measured during experimentally induced visceral pain and during a cognitive task (Stroop color-word test), before and after intervention. The levels of state and trait anxiety as well as self-rated current and perceived stress were also measured before and after the intervention.

RESULTS

CBT did not affect ANS activity during experimentally induced visceral pain and cognitive stress. The sympathetic activity was high, typical for IBS and triggered during both visceral pain and cognitive stress. The levels of state and trait anxiety significantly decreased after the intervention. No significant changes in self-rated current or perceived stress were found.

CONCLUSIONS

Results suggest that face-to-face CBT for IBS improved anxiety- a key psychological mechanism for the IBS pathophysiology, rather than the autonomic stress response to experimentally induced visceral pain and cognitive stress, respectively.

IMPLICATIONS

This study indicates that IBS patients present high levels of stress and difficulties coping with anxiety and ANS activity during visceral pain and a cognitive stress test, respectively. These manifestations of IBS are however not targeted by CBT, and do not seem to be central for the study participants IBS symptoms according to the current and our previous study. Face-to-face CBT for IBS, it does not seem to affect modulation of ANS activity in response to induced visceral pain or cognitive stress. Instead, face-to-face CBT decreased levels of state and trait anxiety. Implications for further studies include that anxiety seems to be important in the IBS pathophysiology, and needs further scientific attention. This is in line with the fear-avoidance model which suggests that anxious responses to pain and discomfort drive hypervigilance to, and (behavioral) avoidance of, symptom provoking stimuli and vice versa. Catastrophic cognitions, hypervigilance and avoidant behavioral responses are proposed to produce vicious circles that withhold and exacerbate pain-related symptoms and disability, and lead to lower quality of life. Larger scale studies of potential autonomic changes are needed in order to elucidate which mechanisms elicit its effects in face-to-face CBT for IBS, and provide new avenues in understanding the pathophysiology of IBS.

The "ick" Factor Matters: Disgust Prospectively Predicts Avoidance in Chemotherapy Patients

BACKGROUND

Chemotherapy can be physically and psychologically demanding. Avoidance and withdrawal are common among patients coping with these demands.

PURPOSE

This report compares established emotional predictors of avoidance during chemotherapy (embarrassment; distress) with an emotion (disgust) that has been unstudied in this context.

METHODS

This report outlines secondary analyses of an RCT where 68 cancer patients undergoing chemotherapy were randomized to mindfulness or relaxation interventions. Self-reported baseline disgust (DS-R), embarrassment (SES-SF), and distress (Distress Thermometer) were used to prospectively predict multiple classes of avoidance post-intervention and at 3 months follow-up. Measures assessed social avoidance, cognitive and emotional avoidance (IES Avoidance), as well as information seeking and treatment adherence (General Adherence Scale).

RESULTS

Repeated-measures ANOVAs evaluated possible longitudinal changes in disgust and forward entry regression models contrasted the ability of the affective variables to predict avoidance. Although disgust did not change over time or vary between groups, greater disgust predicted greater social, cognitive, and emotional avoidance, as well as greater information seeking. Social avoidance was predicted by trait embarrassment and distress predicted non-adherence.

CONCLUSIONS

This report represents the first investigation of disgust's ability to prospectively predict avoidance in people undergoing chemotherapy. Compared to embarrassment and distress, disgust was a more consistent predictor across avoidance domains and its predictive ability was evident across a longer period of time. Findings highlight disgust's role as an indicator of likely avoidance in this health context. Early identification of cancer patients at risk of deleterious avoidance may enable timely interventions and has important clinical implications (ACTRN12613000238774).

Internet-Delivered Cognitive Behavioral Therapy for Children With Pain-Related Functional Gastrointestinal Disorders: Feasibility Study

BACKGROUND

Pain-related functional gastrointestinal disorders (P-FGIDs; eg, irritable bowel syndrome) are highly prevalent in children and associated with low quality of life, anxiety, and school absence. Treatment options are scarce, and there is a need for effective and accessible treatments. Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure exercises is effective for adult and adolescent irritable bowel syndrome, but it has not been evaluated for younger children.

OBJECTIVE

The objective of this study was to assess acceptability, feasibility, and potential clinical efficacy of Internet-CBT for children with P-FGIDs.

METHODS

This was a feasibility study with a within-group design. We included 31 children aged 8-12 years and diagnosed with P-FGID, according to the ROME III criteria. Mean duration of abdominal symptoms at baseline was 3.8 years (standard deviation [SD] 2.6). The treatment was therapist-guided and consisted of 10 weekly modules of exposure-based Internet-CBT. The children were instructed to provoke abdominal symptoms in a graded manner and to engage in previously avoided activities. The parents were taught to decrease their attention to their children's pain behaviors and to reinforce and support their work with the exposures. Assessments included treatment satisfaction, subjective treatment effect, gastrointestinal symptoms, quality of life, pain intensity, anxiety, depression, and school absence. Data were collected at pretreatment, posttreatment, and 6-month follow-up. Means, standard errors (SEs), and Cohen d effect sizes were estimated based on multi-level linear mixed models.

RESULTS

Most children 25/31 (81%) completed 9 or 10 of the 10 treatment modules. Almost all children, 28/31 (90%), reported that the treatment had helped them to deal more effectively with their symptoms, and 27/31 (87%) children declared that their symptoms had improved during the treatment. Assessments from the parents were in accordance with the children's reports. No child or parent reported that the symptoms had worsened. We observed a large within-group effect size on the primary outcome measure, child-rated gastrointestinal symptoms from pretreatment to posttreatment (Cohen d=1.14, P<.001, 95% CI 0.69-1.61), and this effect size was maintained at 6-month follow-up (Cohen d=1.40, P<.001, 95% CI 1.04-1.81). We also observed significant improvements from pretreatment to posttreatment on a wide range of child- and parent-rated measures including quality of life, pain intensity, anxiety, depression, and school absence. All results remained stable or were further improved at 6-month follow-up.

CONCLUSIONS

This study shows that children with longstanding P-FGIDs, and their parents, perceive exposure-based Internet-CBT as a helpful and feasible treatment. The included children improved significantly despite a long duration of abdominal symptoms before the intervention. The treatment shows potential to be highly effective for P-FGIDs. The results need to be confirmed in a randomized controlled trial (RCT).

Face-to-Face Cognitive-Behavioral Therapy for Irritable Bowel Syndrome: The Effects on Gastrointestinal and Psychiatric Symptoms

Irritable bowel syndrome (IBS) is a gastrointestinal disorder linked to disturbances in the gut-brain axis. Visceral hypersensitivity and pain are hallmarks of IBS and linked to the physiological and psychological burden and to the nonadaptive coping with stress. Cognitive-behavioral therapy (CBT) for IBS has proven effective in reducing gastrointestinal and psychiatric symptoms in IBS by means of coping with stress. The present pilot study evaluated for the first time whether CBT for IBS affected visceral sensitivity and pain. Individual CBT was performed for 12 weeks in 18 subjects with IBS and evaluated in terms of visceral sensitivity and pain during rectal distensions using the barostat method and self-rated visceral sensitivity and gastrointestinal and psychiatric symptoms. Visceral discomfort, urge, and pain induced by the barostat were not affected by CBT but were stable across the study. However, the level of self-rated visceral sensitivity and gastrointestinal and psychiatric symptoms decreased after the intervention. Central working mechanisms and increased ability to cope with IBS-symptoms are suggested to play a key role in the alleviation of IBS symptoms produced by CBT.

Internet-Delivered Cognitive Behavior Therapy for Adolescents With Irritable Bowel Syndrome: A Randomized Controlled Trial

OBJECTIVES

Few treatments have been able to effectively manage pediatric irritable bowel syndrome (IBS). Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure for abdominal symptoms is effective for adult IBS. The objective of this study was to evaluate the efficacy of Internet-CBT based on behavioral exposure for adolescents with IBS.

METHODS

Adolescents with IBS fulfilling the Rome III criteria were randomized to either Internet-CBT or a wait-list control. The Internet-CBT was a 10-week intervention where the main component was exposure to IBS symptoms by reduction of avoidance of abdominal symptoms and instead stepwise provocation of symptoms. The primary outcome was total score on Gastrointestinal Symptoms Rating Scale for IBS (GSRS-IBS). Secondary outcomes included adolescent- and parent-rated quality of life and parent-rated gastrointestinal symptoms. Difference between groups was assessed from pretreatment to posttreatment and the Internet-CBT group was also evaluated at 6 months after treatment completion.

RESULTS

A total of 101 adolescents with IBS (13-17 years of age) were included in this study. Dropout rates were low (6%) and all randomized patients were included in intent-to-treat analyses based on mixed effects models. Analyses showed a significant larger pretreatment to posttreatment change on the primary outcome GSRS-IBS (B=-6.42, P=0.006, effect size Cohen's d=0.45, 95% confidence interval (0.12, 0.77)) and on almost all secondary outcomes for the Internet-CBT group compared with the control group. After 6 months, the results were stable or significantly improved.

CONCLUSIONS

Internet-CBT based on exposure exercises for adolescents with IBS can effectively improve gastrointestinal symptoms and quality of life.

Exposure-Based Cognitive Behavior Therapy for Children with Abdominal Pain: A Pilot Trial

Background

Children with pain-related functional gastrointestinal disorders (P-FGIDs) have an increased risk for school absenteeism, depression, anxiety and low quality of life. Exposure-based cognitive behavior therapy (CBT) has shown large treatment effects in adults with irritable bowel syndrome, but has not been tested for children 8–12 years with P-FGIDs.

Aim

The aim of this trial was to test the feasibility, acceptability and potential efficacy of a newly developed exposure-based CBT for children with P-FGIDs.

Method

The children (n = 20) with a P-FGID, were referred by their treating physicians. The participants received 10 weekly sessions of exposure-based CBT and were assessed at pre-treatment, post-treatment and 6-month follow-up.

Results

Children improved significantly on the primary outcome measure pain intensity at post (Cohen’s d = 0.40, p = 0.049) and at 6-month follow-up (Cohen’s d = 0.85, p = 0.004). Improvements were also seen in pain frequency, gastrointestinal symptoms, quality of life, depression, anxiety, school absenteeism and somatic symptoms. Improvements were maintained or further increased at 6-month follow-up. The children engaged in the exposures and were satisfied with the treatment.

Conclusions

Exposure-based CBT for children with P-FGIDs is feasible, acceptable and potentially efficacious.

Exposure-based cognitive behavioral therapy for irritable bowel syndrome. A single-case experimental design across 13 subjects

Irritable bowel syndrome (IBS) is a highly prevalent disorder with a significant impact on quality of life. The presence of psychological symptoms in IBS patients such as catastrophic worry and behavioral avoidance suggests the possible efficacy of cognitive behavioral interventions. Exposure-based cognitive behavioral therapy (CBT) has proven to be a promising approach but has only been investigated in a few studies and mainly via the Internet. Therefore, the aims of this study were to extend and replicate previous findings and to evaluate whether an individual, face-to-face, exposure-based CBT leads to improvement in gastrointestinal symptoms, pain catastrophizing, avoidance behavior and quality of life in IBS patients. Thirteen patients with IBS according to Rome III criteria participated in a single-case experimental study using a five-week baseline and a subsequent twelve-session intervention phase focusing on psycho-education, mindfulness and in vivo exposure. Standardized measurement of gastrointestinal symptoms, pain catastrophizing, avoidance behavior and quality of life was conducted weekly during baseline as well as intervention phase and at six-month follow-up. Results showed that over 70% of patients improved significantly on gastrointestinal symptoms, pain catastrophizing, and quality of life. Effects on avoidance behavior were modest. These results strengthen and extend earlier findings and provide further support for the efficacy of exposure-based strategies for IBS.

Stress and the Microbiota-Gut-Brain Axis in Visceral Pain: Relevance to Irritable Bowel Syndrome

Visceral pain is a global term used to describe pain originating from the internal organs of the body, which affects a significant proportion of the population and is a common feature of functional gastrointestinal disorders (FGIDs) such as irritable bowel syndrome (IBS). While IBS is multifactorial, with no single etiology to completely explain the disorder, many patients also experience comorbid behavioral disorders, such as anxiety or depression; thus, IBS is described as a disorder of the gut-brain axis. Stress is implicated in the development and exacerbation of visceral pain disorders. Chronic stress can modify central pain circuitry, as well as change motility and permeability throughout the gastrointestinal (GI) tract. More recently, the role of the gut microbiota in the bidirectional communication along the gut-brain axis, and subsequent changes in behavior, has emerged. Thus, stress and the gut microbiota can interact through complementary or opposing factors to influence visceral nociceptive behaviors. This review will highlight the evidence by which stress and the gut microbiota interact in the regulation of visceral nociception. We will focus on the influence of stress on the microbiota and the mechanisms by which microbiota can affect the stress response and behavioral outcomes with an emphasis on visceral pain.

Utilization and efficacy of internet-based eHealth technology in gastroenterology: a systematic review

OBJECTIVE

While there have been several reviews exploring the outcomes of various eHealth studies, none have been gastroenterology-specific. This paper aims to evaluate the research conducted within gastroenterology which utilizes internet-based eHealth technology to promote physical and psychological well-being.

MATERIAL AND METHODS

A systematic literature review of internet-based eHealth interventions involving gastroenterological cohorts was conducted. Searched databases included: EbSCOhost Medline, CINAHL, and PsycINFO. Inclusion criteria were studies reporting on eHealth interventions (both to manage mental health problems and somatic symptoms) in gastroenterology, with no time restrictions. Exclusion criteria were non-experimental studies, or studies using only email as primary eHealth method, and studies in language other than English.

RESULTS

A total of 17 papers were identified; seven studies evaluated the efficacy of a psychologically oriented intervention (additional two provided follow-up analyses exploring the original published data) and eight studies evaluated disease management programs for patients with either irritable bowel syndrome, inflammatory bowel disease (IBD) or celiac disease. Overall, psychological eHealth interventions were associated with significant reductions in bowel symptoms and improvement in quality of life (QoL) that tended to continue up to 12 months follow up. The eHealth disease management was shown to generally improve QoL, adherence, knowledge about the disease, and reduce healthcare costs in IBD, although the studies were associated with various methodological problems, and thus, this observation should be confirmed in well-designed interventional studies.

CONCLUSIONS

Based on the evidence to date, eHealth internet-based technology is a promising tool that can be utilized to both promote and enhance gastrointestinal disease management and mental health.

Prediction of symptomatic improvement after exposure-based treatment for irritable bowel syndrome

BACKGROUND

Several studies show that psychological treatments relieve symptoms for patients suffering from irritable bowel syndrome (IBS). However, there are no consistent findings that show what patient characteristics make a psychological treatment more or less likely to result in improvement. We have previously conducted a study of a newly developed internet-delivered cognitive behavioral therapy (ICBT) that emphasized exposure to IBS symptoms and IBS-related situations and reduced symptom-related avoidance. The study showed that the treatment led to improvement in IBS symptoms compared to a waiting list and that treatment gains were maintained over a 15-18 month follow-up period. The aim of the present study was to investigate several possible predictors of short- and long-term treatment outcome in terms of symptom improvement, based on data collected in the previously conducted treatment trial.

METHODS

Demographics, comorbid psychological distress, IBS-related fear and avoidance behaviors, and IBS-related disability were investigated as predictors of treatment outcome in the sample consisting of 79 participants diagnosed with IBS who had undergone 10 weeks of ICBT. Predictors that were significantly correlated with symptom levels at post-treatment and follow-up were entered into multiple regression analyses that controlled for pre-treatment symptom levels.

RESULTS

There were measures within each domain, i.e., comorbid psychological distress, IBS-related fear and avoidance behaviors, and IBS-related disability, with the exception of demographic data, that were correlated with the symptom levels at post-treatment and follow-up. However, when these were entered into a multiple regression analyses that controlled for pre-treatment levels, none remained a significant predictor of the post-treatment and follow-up symptomatic status.

CONCLUSIONS

The study did not find any individual characteristics that made patients more or less likely to respond to the exposure-based ICBT. The finding that comorbid psychological distress did not predict outcome is in accordance with previous studies. Reliable predictors for response to any type of psychological treatment for IBS remain to be established.

Psychosocial predictors of irritable bowel syndrome diagnosis and symptom severity

OBJECTIVE

This study explored the role of psychosocial factors in predicting both membership to either an irritable bowel syndrome (IBS) or control group, and the severity of IBS symptoms.

METHODS

A total of 149 participants (82 IBS and 67 controls) completed a battery of self-report inventories assessing disposition and environment, cognitive processes, and psychological distress. Logistic regression analyses were used to assess predictive contribution of psychosocial variables to IBS diagnosis. Hierarchical linear regression was then used to assess the relationship of psychosocial variables with the severity of IBS symptoms.

RESULTS

Significant predictors of IBS were found to be alexithymia, the defectiveness/shame schema, and four coping dimensions (active coping, instrumental support, self-blame, and positive reframing), χ(2) (6, N=130)=46.99, p<.001, with predictive accuracy of 72%. Significant predictors of IBS symptom severity were two of the alexithymia subscales (difficulty identifying feelings, and difficulty describing feelings), gender, the schemas of defectiveness/shame and entitlement, and global psychological distress. This model predicted IBS severity F (6, 64)=16.94, p<.001 and accounted for 61.3% of the variability in IBS severity scores.

CONCLUSION

Psychosocial variables account for a large percentage of the differences between an IBS and control group, as well as the variance of symptoms experienced within the IBS group. Alexithymia and the defectiveness schema appear to be related to both IBS and symptom severity.

Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis

Background

Mindfulness-based therapy (MBT) has been used effectively to treat a variety of physical and psychological disorders, including depression, anxiety, and chronic pain. Recently, several lines of research have explored the potential for mindfulness-therapy in treating somatization disorders, including fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome.

Methods

Thirteen studies were identified as fulfilling the present criteria of employing randomized controlled trials to determine the efficacy of any form of MBT in treating somatization disorders. A meta-analysis of the effects of mindfulness-based therapy on pain, symptom severity, quality of life, depression, and anxiety was performed to determine the potential of this form of treatment.

Findings

While limited in power, the meta-analysis indicated a small to moderate positive effect of MBT (compared to wait-list or support group controls) in reducing pain (SMD  = −0.21, 95% CI: −0.37, −0.03; p<0.05), symptom severity (SMD  = −0.40, 95% CI: −0.54, −0.26; p<0.001), depression (SMD  = −0.23, 95% CI: −0.40, −0.07, p<0.01), and anxiety (SMD  = −0.20, 95% CI: −0.42, 0.02, p = 0.07) associated with somatization disorders, and improving quality of life (SMD  = 0.39, 95% CI: 0.19, 0.59; p<0.001) in patients with this disorder. Subgroup analyses indicated that the efficacy of MBT was most consistent for irritable bowel syndrome (p<0.001 for pain, symptom severity, and quality of life), and that mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MCBT) were more effective than eclectic/unspecified MBT.

Conclusions

Preliminary evidence suggests that MBT may be effective in treating at least some aspects of somatization disorders. Further research is warranted.

A systematic review of minimal-contact psychological treatments for symptom management in irritable bowel syndrome

OBJECTIVE

Psychological treatments are effective in alleviating symptoms of IBS but are not widely available. The need for wider dissemination of treatments has encouraged the development of 'minimal-contact' therapies requiring fewer resources than existing psychological treatments which rely on face-to-face contact.

METHOD

Using comprehensive search terms, the Embase, Medline and PsychInfo databases (all years) were searched.

RESULTS

Twelve studies--nine RCTs and three non-controlled preliminary studies - meeting inclusion criteria were reviewed and assessed for quality using objective criteria. Apart from one study of expressive writing, all interventions were based on cognitive (and/or) behavioural principles or hypnosis and tended to be adaptations of existing therapist-led interventions. Compared to control conditions, minimal-contact interventions were efficacious, the majority of studies showing statistically significant improvements by the end of treatment. For cognitive-behaviour-therapy-based interventions effects sizes were large. The two studies that compared minimal-contact with therapist-delivered interventions broadly suggest comparable outcomes between these modalities.

CONCLUSIONS

Minimal-contact cognitive-behavioural interventions show promise in the treatment of IBS. Because of the lower quality of studies of hypnosis and those involving interventions delivered entirely remotely, further support is needed before such approaches can be recommended for widespread use. More generally, future research should use representative samples, active control conditions, and intention to treat analysis. Nonetheless, existing high quality studies suggest that minimal-contact therapies may be a safe, effective means of achieving scaleability of psychological treatments for IBS.

Mindfulness-based interventions for physical conditions: a narrative review evaluating levels of evidence

Research on mindfulness-based interventions (MBIs) for treating symptoms of a wide range of medical conditions has proliferated in recent decades. Mindfulness is the cultivation of nonjudgmental awareness in the present moment. It is both a practice and a way of being in the world. Mindfulness is purposefully cultivated in a range of structured interventions, the most popular of which is mindfulness-based stress reduction (MBSR), followed by mindfulness-based cognitive therapy (MBCT). This paper begins with a discussion of the phenomenological experience of coping with a chronic and potentially life-threatening illness, followed by a theoretical discussion of the application of mindfulness in these situations. The literature evaluating MBIs within medical conditions is then comprehensively reviewed, applying a levels of evidence rating framework within each major condition. The bulk of the research looked at diagnoses of cancer, pain conditions (chronic pain, low back pain, fibromyalgia, and rheumatoid arthritis), cardiovascular disease, diabetes, human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), and irritable bowel syndrome. Most outcomes assessed are psychological in nature and show substantial benefit, although some physical and disease-related parameters have also been evaluated. The field would benefit from more adequately powered randomized controlled trials utilizing active comparison groups and assessing the moderating role of patient characteristics and program "dose" in determining outcomes.

Meditation over medication for irritable bowel syndrome? On exercise and alternative treatments for irritable bowel syndrome

Complimentary alternative treatment regimens are widely used in irritable bowel syndrome (IBS), but the evidence supporting their use varies. For psychological treatment options, such as cognitive behavioral therapy, mindfulness, gut-directed hypnotherapy, and psychodynamic therapy, the evidence supporting their use in IBS patients is strong, but the availability limits their use in clinical practice. Dietary interventions are commonly included in the management of IBS patients, but these are primarily based on studies assessing physiological function in relation to dietary components, and to a lesser degree upon research examining the role of dietary components in the therapeutic management of IBS. Several probiotic products improve a range of symptoms in IBS patients. Physical activity is of benefit for health in general and recent data implicates its usefulness also for IBS patients. Acupuncture does not seem to have an effect beyond placebo in IBS. A beneficial effect of some herbal treatments has been reported.

Meditative therapies for reducing anxiety: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Anxiety disorders are among the most common psychiatric disorders and meditative therapies are frequently sought by patients with anxiety as a complementary therapy. Although multiple reviews exist on the general health benefits of meditation, no review has focused on the efficacy of meditation for anxiety specifically.

METHODS

Major medical databases were searched thoroughly with keywords related to various types of meditation and anxiety. Over 1,000 abstracts were screened, and 200+ full articles were reviewed. Only randomized controlled trials (RCTs) were included. The Boutron (Boutron et al., 2005: J Clin Epidemiol 58:1233-1240) checklist to evaluate a report of a nonpharmaceutical trial (CLEAR-NPT) was used to assess study quality; 90% of the authors were contacted for additional information. Review Manager 5 was used for meta-analysis.

RESULTS

A total of 36 RCTs were included in the meta-analysis (2,466 observations). Most RCTs were conducted among patients with anxiety as a secondary concern. The study quality ranged from 0.3 to 1.0 on the 0.0-1.0 scale (mean = 0.72). Standardized mean difference (SMD) was -0.52 in comparison with waiting-list control (p < .001; 25 RCTs), -0.59 in comparison with attention control (p < .001; seven RCTs), and -0.27 in comparison with alternative treatments (p < .01; 10 RCTs). Twenty-five studies reported statistically superior outcomes in the meditation group compared to control. No adverse effects were reported.

CONCLUSIONS

This review demonstrates some efficacy of meditative therapies in reducing anxiety symptoms, which has important clinical implications for applying meditative techniques in treating anxiety. However, most studies measured only improvement in anxiety symptoms, but not anxiety disorders as clinically diagnosed.

Symptoms catastrophizing versus social hypervigilance in irritable bowel syndrome patients

Western studies have revealed that symptoms catastrophizing (SC), a self-focused illness coping pattern, mediates poorer health outcomes in irritable bowel syndrome (IBS) patients. In light of the collective orientation of Chinese culture, an others-focused illness coping pattern named "symptoms-related social hypervigilance" (SSH) was constructed and explored together with SC in the current study. A cross-sectional questionnaire survey with 309 IBS patients recruited by 100% consecutive sampling was conducted. Exploratory factor analysis on the SSH scale provided a 9-item 3-factor solution. The three factors were 1) Anticipating negative perceptions from others; 2) Hiding symptoms in social situations; and 3) Assuming responsibility for total symptoms control. SC showed partial mediator properties between IBS symptoms severity and lowered health-related quality of life. Whereas SSH did not show similar mediating effects, it was associated with 'proactive' illness behaviors which, if excessive, can lead to relentless pursuit of total symptoms elimination.

Acceptability, effectiveness, and cost-effectiveness of internet-based exposure treatment for irritable bowel syndrome in a clinical sample: a randomized controlled trial

BACKGROUND

Internet-based cognitive behavior therapy (ICBT) has shown promising effects in the treatment of irritable bowel syndrome (IBS). However, to date no study has used a design where participants have been sampled solely from a clinical population. We aimed to investigate the acceptability, effectiveness, and cost-effectiveness of ICBT for IBS using a consecutively recruited sample from a gastroenterological clinic.

METHODS

Sixty-one patients were randomized to 10 weeks of ICBT (n = 30) or a waiting list control (n = 31). The ICBT was guided by an online therapist and emphasized acceptance of symptoms through exposure and mindfulness training. Severity of IBS symptoms was measured with the Gastrointestinal symptom rating scale--IBS version (GSRS-IBS). Patients in both groups were assessed at pre- and post-treatment while only the ICBT group was assessed 12 months after treatment completion. Health economic data were also gathered at all assessment points and analyzed using bootstrap sampling.

RESULTS

Fifty of 61 patients (82%) completed the post-treatment assessment and 20 of 30 patients (67%) in the ICBT group were assessed at 12-month follow-up. The ICBT group demonstrated significantly (p < .001) larger improvements on the IBS-related outcome scales than the waiting list group. The between group effect size on GSRS-IBS was Cohen's d = 0.77 (95% CI: 0.19-1.34). Similar effects were noted on measures of quality of life and IBS-related fear and avoidance behaviors. Improvements in the ICBT group were maintained at 12-month follow-up. The ICBT condition was found to be more cost-effective than the waiting list, with an 87% chance of leading to reduced societal costs combined with clinical effectiveness. The cost-effectiveness was sustained over the 12-month period.

CONCLUSIONS

ICBT proved to be a cost-effective treatment when delivered to a sample recruited from a gastroenterological clinic. However, many of the included patients dropped out of the study and the overall treatment effects were smaller than previous studies with referred and self-referred samples. ICBT may therefore be acceptable and effective for only a subset of clinical patients. Study dropout seemed to be associated with severe symptoms and large impairment. Objective and empirically validated criteria to select which patients to offer ICBT should be developed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00844961.

Internet-delivered exposure-based treatment vs. stress management for irritable bowel syndrome: a randomized trial

OBJECTIVES

Our research group has developed an internet-delivered cognitive behavioral treatment (ICBT) for irritable bowel syndrome (IBS). We compared ICBT with internet-delivered stress management (ISM) for IBS to assess whether the effects of ICBT are specific.

METHODS

This was a randomized controlled trial, including 195 self-referred participants diagnosed with IBS. The treatment interventions lasted for 10 weeks and included an online therapist contact. The ICBT emphasized acceptance of symptoms through exposure to IBS symptoms and related negative feelings. The ICBT also included mindfulness training. The ISM emphasized symptom control through relaxation techniques, dietary adjustments, and problem-solving skills. Severity of IBS symptoms was measured with the gastrointestinal symptom rating scale-IBS version (GSRS-IBS). Credibility of the treatments and expectancy of improvement were assessed with the treatment credibility scale. The participants' perceived therapeutic alliance with their online therapist was measured with the working alliance inventory.

RESULTS

At post-treatment and 6-month follow-up, 192 (99%) and 169 (87%) participants returned data, respectively. At post-treatment and 6-month follow-up, we found significant differences on the GSRS-IBS, favoring ICBT. The difference on GSRS-IBS scores was 4.8 (95% confidence interval (CI): 1.2-8.4) at post-treatment and 5.9 (95% CI: 1.9-9.9) at 6-month follow-up. There were no significant differences on the treatment credibility scale or the working alliance inventory between the groups.

CONCLUSIONS

Internet-delivered CBT has specific effects that cannot be attributed only to treatment credibility, expectancy of improvement, therapeutic alliance, or attention. Furthermore, a treatment based on exposure exercises specifically tailored for IBS may be a better treatment option than general stress and symptom management for IBS patients. ICBT is a promising treatment modality for IBS as it can be offered to IBS patients in much larger scale than conventional psychological treatments.

Association of participation in a mindfulness programme with bowel symptoms, gastrointestinal symptom-specific anxiety and quality of life

BACKGROUND

Stress perception and GI-specific anxiety play key roles in irritable bowel syndrome (IBS). Mindfulness-based stress reduction (MBSR) is a widely available stress reduction course, which has not been evaluated for IBS.

AIM

To determine whether participation in MBSR is associated with improvement in bowel symptoms, GI-specific anxiety, and IBS-Quality of Life.

METHODS

This is a prospective study of 93 participants in MBSR. We applied measures of Rome III IBS status, bowel symptoms (IBS-Severity Scoring System, IBS-SSS), IBS-Quality of Life (IBS-QOL), GI-specific anxiety (Visceral Sensitivity Index, VSI), mindfulness (Five Facet Mindfulness Questionnaire-FFMQ), and functional status (SF-8) at baseline and 2 and 6 months after enrolment.

RESULTS

At 2 months, participation in MBSR was associated with small nonsignificant changes in IBS-SSS, IBS-QOL and VSI: d = -0.25, d = 0.08, d = -0.16, respectively. At 6 months, there was no significant change in IBS-SSS (d = -0.36); whereas for IBS-QOL and VSI there were significant improvements (IBS-QOL: d = 0.33, P = 0.044; VSI: d = -0.40, P = 0.014). For patients meeting Rome III IBS criteria (n = 43), changes in IBS-SSS, IBS-QOL and VSI were not statistically significant, but there was a significant correlation between the change in VSI and the change in FFMQ across the three time periods (r = 0.33).

CONCLUSIONS

Participation in MBSR is associated with improvement IBS-related quality of life and GI-specific anxiety. Randomised controlled trials are warranted to further assess the role of MBSR for IBS symptomatology.

Cost-effectiveness of internet-based cognitive behavior therapy for irritable bowel syndrome: results from a randomized controlled trial

BACKGROUND

Irritable Bowel Syndrome (IBS) is highly prevalent and is associated with a substantial economic burden. Cognitive behavior therapy (CBT) has been shown to be effective in treating IBS. The aim of this study was to evaluate the cost-effectiveness of a new treatment alternative, internet-delivered CBT based on exposure and mindfulness exercises.

METHODS

Participants (N = 85) with IBS were recruited through self-referral and were assessed via a telephone interview and self-report measures on the internet. Participants were randomized to internet-delivered CBT or to a discussion forum. Economic data was assessed at pre-, post- and at 3-month and 1 year follow-up.

RESULTS

Significant cost reductions were found for the treatment group at $16,806 per successfully treated case. The cost reductions were mainly driven by reduced work loss in the treatment group. Results were sustained at 3-month and 1 year follow-up.

CONCLUSIONS

Internet-delivered CBT appears to generate health gains in IBS treatment and is associated with cost-savings from a societal perspective.

Centrally acting therapies for irritable bowel syndrome

Irritable bowel syndrome (IBS) and other functional gastrointestinal (GI) disorders typically defy traditional diagnostic methods based on structural abnormalities, and has led to the emergence of the discipline of neurogastroenterology or the study of the "brain-gut axis," which is based on dysregulation of neuroenteric pathways as a key pathophysiological feature of IBS. Centrally acting treatments can influence these pathways and improve the clinical manifestations of pain and bowel dysfunction associated with this disorder. To successfully implement these treatment strategies, it is important to recognize their dual effects on brain and gut, understanding the nature and severity of the GI symptoms and their psychosocial concomitants, and applying them within the context of the patient's understanding of their value.

The promise and pitfalls of the internet for cognitive behavioral therapy

Internet-administered cognitive behavior therapy is a promising new way to deliver psychological treatment. There are an increasing number of controlled trials in various fields such as anxiety disorders, mood disorders and health conditions such as headache and insomnia. Among the advantages for the field of cognitive behavior therapy is the dissemination of the treatment, being able to access treatment from a distance, and possibilities to tailor the interventions. To date, studies in which large effects have been obtained have included patient support from a clinician. Recent trials suggest that this support may come from non-clinicians and that therapist effects are minimal. Since studies also suggest that internet-delivered cognitive behavior therapy can be equally effective as face-to-face cognitive behavior therapy, this is a finding that may have implications for CBT practitioners. However, there are other aspects to consider for implementation, as while clinicians may hold positive attitudes towards internet-delivered CBT a recent study suggested that patients are more skeptical and may prefer face-to-face treatment. In the present work, I argue that internet-delivered CBT may help to increase adherence to treatment protocols, that training can be facilitated by means of internet support, and that research on internet interventions can lead to new insights regarding what happens in regular CBT. Moreover, I conclude that internet-delivered CBT works best when support is provided, leaving an important role for clinicians who can incorporate internet treatment in their services. However, I also warn against disseminating internet-delivered CBT to patients for whom it is not suitable, and that clinical skills may suffer if clinicians are trained and practice mainly using the internet.

Long-term follow-up of internet-delivered exposure and mindfulness based treatment for irritable bowel syndrome

We conducted a follow-up of a previously reported study of internet-delivered cognitive behavior therapy (CBT) for IBS, based on exposure and mindfulness exercises (Ljótsson et al. (2010). Internet-delivered exposure and mindfulness based therapy for irritable bowel syndrome - a randomized controlled trial. Behaviour Research and Therapy, 48, 531-539). Seventy-five participants from the original sample of 85 (88%) reported follow-up data at 15-18 months (mean 16.4 months) after completing treatment. The follow-up sample included participants from both the original study's treatment group and waiting list after it had been crossed over to treatment. Intention-to-treat analysis showed that treatment gains were maintained on all outcome measures, including IBS symptoms, quality of life, and anxiety related to gastrointestinal symptoms, with mainly large effect sizes (within-group Cohen's d=0.78-1.11). A total of fifty participants (59% of the total original sample; 52% of the original treatment group participants and 65% of the original waiting list participants) reported adequate relief of symptoms. Improvements at follow-up were more pronounced for the participants that had completed the full treatment and maintenance of improvement did not seem to be dependent on further treatment seeking. This study suggests that internet-delivered CBT based on exposure and mindfulness has long-term beneficial effects for IBS-patients.

Internet-delivered exposure and mindfulness based therapy for irritable bowel syndrome--a randomized controlled trial

The aim of this study was to investigate if cognitive behavior therapy (CBT) based on exposure and mindfulness exercises delivered via the Internet would be effective in treating participants with irritable bowel syndrome (IBS). Participants were recruited through self-referral. Eighty-six participants were included in the study and randomized to treatment or control condition (an online discussion forum). One participant was excluded after randomization. The main outcome measure was IBS-symptom severity and secondary measures included IBS-related quality of life, GI-specific anxiety, depression and general functioning. Participants were assessed at pre-treatment, post-treatment and 3 month follow-up (treatment condition only). Four participants (5% of total sample) in the treatment condition did not participate in post-treatment assessment. Participants in the treatment condition reported a 42% decrease and participants in the control group reported a 12% increase in primary IBS-symptoms. Compared to the control condition, participants in the treatment group improved on all secondary outcome measures with a large between group effect size on quality of life (Cohen's d = 1.21). We conclude that CBT-based on exposure and mindfulness delivered via the Internet can be effective in treating IBS-patients, alleviating the total burden of symptoms and increasing quality of life.