The combination of medical treatment plus multicomponent behavioral therapy is superior to medical treatment alone in the therapy of irritable bowel syndrome

Treating disorders of brain-gut interaction with multidisciplinary integrated care. Moving towards a new standard of care

Disorders of brain-gut interaction (DGBI) are highly prevalent in our community with a negative burden on the quality of life and function. Symptoms are frequently food-induced, and psychological disorders are commonly co-morbid and contribute greatly to symptom severity and healthcare utilization, which can complicate management. Pathophysiological contributors to the development and maintenance of DGBI are best appreciated within the biopsychosocial model of illness. Established treatments include medical therapies targeting gastrointestinal physiology, luminal microbiota or visceral sensitivity, dietary treatments including dietary optimization and specific therapeutic diets such as a low-FODMAP diet, and psychological interventions. The traditional "medical model" of care, driven predominantly by doctors, poorly serves sufferers of DBGI, with research indicating that a multidisciplinary, integrated-care approach produces better outcomes. This narrative review explores the current evidence for multidisciplinary care and provides the best practice recommendations for physicians and healthcare systems managing such patients.

The Prevalence of Irritable Bowel Syndrome and Its Co-existence With Migraine in Medical and Non-medical Students at Al-Baha University, Saudi Arabia

BACKGROUND

It was hypothesized that the prevalence of irritable bowel syndrome (IBS) and migraine and their co-existence are higher among medical students. In this study, we aim to establish the prevalence of IBS and migraine in the medical and non-medical students at Al-Baha University, Saudi Arabia, and to observe the association and relationship between IBS and migraine using the Rome IV diagnostic criteria for IBS and the International Classification of Headache Disorders (ICHD)-3 criteria for migraine.

METHODOLOGY

This cross-sectional study was done on the Saudi Arabian campus of Al-Baha University between July 2022 and July 2023. Al-Baha city-dwelling male and female college students aged 18 to 29 comprised the study population. A self-administered electronic questionnaire was sent online to determine the prevalence of IBS and migraine, in addition to associated risk factors. The questionnaire consisted of three sections: demographic and lifestyle data, the Rome IV criteria for diagnosing and subclassifying IBS, and the ICHD-3 criteria for diagnosing migraine.

RESULTS

The study was conducted among 452 participants with a mean age of 21.64 years. The majority of participants were not from medical schools. The majority of medical and non-medical participants were male, at 66.6% and 63.1%, respectively. In our study, 36.9% of the individuals reported having a first-degree relative diagnosed with IBS, whereas 2.7% reported having IBS themselves. Regarding migraine, 17.9% of respondents claimed to have a first-degree relative with migraine, while 6.9% of respondents themselves reported experiencing migraine. Regarding IBS prevalence, there was no significant difference between participants from non-MBBS colleges and MBBS colleges. Similarly, there was no significant difference in migraine prevalence between these two groups (92.0% vs. 95.4%, p=0.185).

CONCLUSION

The current study contributes significantly to our understanding of the prevalence of IBS and migraines among medical students, as well as these individuals' demographic characteristics, familial histories, and aggravating variables.

The role of psychological factors in functional gastrointestinal disorders: a systematic review and meta-analysis

PURPOSE

To systematically reevaluate the role of psychological factors in functional gastrointestinal disorders (FGIDs) and thus provide a scientific basis for the psychological treatment of FGIDs.

METHODS

A literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane Library databases from January 2018 to August 2022 for researches on psychological factors affecting patients with functional gastrointestinal disorders. Meta-analysis was carried out with Stata17.0 after the screening, extraction, and evaluation of article quality.

RESULTS

The search included 22 articles with 2430 patients in the FGIDs group and 12,397 patients in the healthy controls. Meta-analysis showed anxiety [(pooled SMD = 0.74, 95%CI: 0.62 ~ 0.86, p < 0.000) (pooled OR = 3.14, 95%CI: 2.47 ~ 4.00, p < 0.000)], depression [(pooled SMD = 0.79, 95%CI: 0.63 ~ 0.95, p < 0.000) (pooled OR = 3.09, 95%CI: 2.12 ~ 4.52, p < 0.000)], mental disorders (pooled MD =  -5.53, 95%CI: -7.12 ~  -3.95, p < 0.05), somatization (pooled SMD = 0.92, 95%CI: 0.61 ~ 1.23, p < 0.000), and sleep disorders (pooled SMD = 0.69, 95%CI: 0.04 ~ 1.34, p < 0.05) are risk factors for functional gastrointestinal disorders.

CONCLUSION

There is a significant association between psychological factors and FGIDs. Interventions such as anti-anxiety drugs, antidepressants, and behavioral therapy are of great clinical significance in reducing FGIDs risk and improving prognosis.

A Biofeedback-Assisted Stress Management Program for Patients with Irritable Bowel Syndrome: a Randomised Controlled Trial

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that affects the functionality and quality of life of the affected persons. There is a well-established detrimental reciprocal relationship between stress and IBS. In this randomised controlled trial, IBS patients were randomly assigned to an 8-week biofeedback-assisted stress management intervention group (n=24) or a control group (n=22). Psychometric measures were performed at baseline and following intervention to assess perceived stress, health locus of control and depressive symptoms. In patients of the intervention group, perceived stress and symptoms of depression were significantly decreased, while the sense of control over health was increased. The intervention program was beneficial to the health and quality of life of individuals with IBS. Future randomised controlled studies with larger samples and longer follow-up are required to establish the effectiveness of stress-management techniques in functional gastrointestinal disorders.

Psychotherapeutic Interventions in Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a frequent functional gastrointestinal disorder. The patients complain about various symptoms like change in bowel habits, constipation or diarrhea, abdominal pain, and meteorism leading to a great reduction in quality of life. The pathophysiology is complex and best explained using the biopsychosocial model encompassing biological, psychological as well as (psycho)social factors. In line with the multitude of underlying factors, the treatment is comprised of a multitude of components. Often, patients start with lifestyle changes and dietary advice followed by medical treatment. However, also psychotherapy is an important treatment option for patients with IBS and should not be restricted to those with psychiatric comorbidities. Several evidence-based psychotherapeutic treatment options exist such as psychoeducation, self-help, cognitive behavioral therapy, psychodynamic psychotherapy, hypnotherapy, mindfulness-based therapy, and relaxation therapy which will be discussed in the present review.

Psychological Interventions for Irritable Bowel Syndrome and Inflammatory Bowel Diseases

Psychological interventions have been designed and implemented effectively in a wide range of medical conditions, including Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Diseases (IBD). The psychological treatments for IBS and IBD with the strongest evidence base include: cognitive behavioral therapy, hypnosis, and mindfulness-based therapies. The evidence for each of these therapies is reviewed here for both IBS and IBD. In general, there is a stronger and larger evidence base to support the use of psychological interventions in IBS compared with IBD. This is likely due to the high level of psychiatric comorbidity associated with IBS and the involvement of the stress-response in symptom presentation of IBS. Further research in psychosocial interventions for IBD is necessary. Finally, the importance of conceptualizing both IBS and IBD in a biopsychosocial model is discussed and several resources for accessing Clinical Health Psychology materials and referrals are provided.

Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis

Previous meta-analyses have shown that psychotherapy improves gastrointestinal symptoms in adults with irritable bowel syndrome (IBS); however, the impact on functioning in daily activities is unknown. Meta-analysis was used to estimate the effect of psychotherapy on mental health and daily functioning in adults with IBS. An extensive literature search located 28 eligible randomized controlled trials (RCTs) providing outcome data for mental health and 18 RCTs providing data for daily functioning. Compared to a mixed group of control conditions, psychotherapy produced significantly greater improvements to mental health (d-=0.41) and daily functioning (d-=0.43). Cognitive behavior therapy (CBT) was evaluated in the largest number of trials (21 trials), followed by hypnosis (4 trials), psychodynamic (3 trials), and relaxation (2 trials). The psychotherapeutic modalities were comparable with respect to their effect on mental health. CBT produced the greatest improvements to daily functioning, and this effect was significantly larger than that produced by relaxation therapy. These results have important clinical implications for treatment of adults with IBS.

Prevalence of Irritable Bowel Syndrome (IBS), Migraine and Co-Existing IBS-Migraine in Medical Students

INTRODUCTION

Irritable Bowel Syndrome (IBS) and migraine frequently co-exist. Stress is a major contributing factor for both. Our medical students are subjected to stress related to the implicit responsibility of courses. But the prevalence of IBS, migraine and co-existing migraine in medical students is not known.

AIM

To estimate the prevalence of migraine, IBS and co-existing IBS and migraine among medical students. A Cross-Sectional Survey.

MATERIALS AND METHODS

Self-reported questionnaire based study, was conducted in which migraine was defined according to International Headache Society (IHS) criteria while IBS by both Asian criteria and Rome III criteria. Both preclinical (n=142) and clinical students (n=151) of four medical colleges (government and private) of Dhaka and Sylhet district participated in the study. Statistical Analysis: Student's t-test and chi-square test were used to compare the distributions of continuous data and categorical data respectively with significance level set at 0.05 or less.

RESULTS

Among the 293 students (mean age 21.09 ± 2.24 years) volunteered in the study (Males= 177), 14 (4.8%, 11 males, 3 females, p = 0.175) met the criteria for IBS with comparable prevalence among preclinical and clinical (4.2% vs. 5.3%, p = 0.787) students from both private and government institutions (2.1% vs. 7.2%, p = 0.055). IBS-D was the most prevalent subtype (n = 8, M = 6) and abdominal pain relieved by defecation (n = 11), was the most prevalent symptom. Fifty percent (n = 7) of IBS patients considered their bowel habit as normal. Among the 221 (75.4%) students with headache, only 51 (17.4%, 20 males and 31 females, p = 0.001) were diagnosed of migraine, with comparable prevalence among preclinical and clinical students (16.2% vs. 18.5%, p = 0.645). Only 17 (33%) subjects with migraine had accompanying aura. Common triggers were stress (n = 43), lack of sleep (n = 42), and daily life events. Twelve (23.5%) subjects with migraine had migraine-associated frequent disability. Only two female students with IBS-D (14.3%) had concomitant IBS and migraine.

CONCLUSION

IBS and concomitant migraine - IBS prevalence was found to be low in our medical students, but migraine prevalence corresponds to other countries as well as in medical students.

Identifying effective techniques within psychological treatments for irritable bowel syndrome: a meta-analysis

OBJECTIVES

Psychological interventions can alleviate the symptoms of irritable bowel syndrome (IBS) and psychological distress commonly reported among IBS sufferers. However, the theoretical underpinnings and intervention techniques used by such interventions vary considerably. This study aimed to identify which theoretical approaches and techniques lead to greater improvements in IBS symptoms and psychological well-being within psychological interventions for IBS.

METHODS

Outcome data were extracted from 48 randomized controlled trials testing psychological treatments for IBS. Theoretical intervention targets and intervention techniques of each study were identified. Cumulative effect sizes were calculated for pain, bowel dysfunction, composite symptom scores, psychological distress, and health-related quality of life. Comparative analyses contrasted the effect sizes of studies which included each intervention technique to those which did not.

RESULTS

Cumulatively, interventions significantly improved all outcomes, with effect sizes (Hedges' g) ranging from 0.32 to 0.64. Interventions which stated a theoretical intervention target, prompted self-monitoring of symptoms and cognitions, provided tailored feedback linking symptoms and cognitions, utilized problem solving or assertiveness training and provided general support had greater effects upon symptom and well-being outcomes than interventions which did not (all P<.05). Across all studies, improvements in psychological distress were associated with improvements in composite symptom scores (P<.01).

CONCLUSIONS

This study identifies a set of techniques associated with improvements in IBS symptoms and psychological well-being in existing interventions, and provides initial evidence for the link between improvements in psychological distress and IBS composite symptom scores. These findings can aid the development and refinement of psychological treatments for IBS.

Psychological therapies in patients with irritable bowel syndrome: a systematic review and meta-analysis of randomized controlled trials

Background. Irritable bowel syndrome (IBS) is a poorly understood disease with few effective treatments. Psychosocial factors are believed to contribute to the pathogenesis of IBS. Objective. To evaluate the evidence for psychological therapies in IBS treatment. Methods. We searched six medical databases through February 6, 2014, for randomized controlled trials (RCTs) of psychological therapies for the treatment of IBS. Two independent reviewers identified the RCTs, extracted the data, and assessed trial quality. We used the random-effect model to pool standardized mean difference (SMD) and 95% confidence interval (CI) across trials. Results. 15 RCTs that mostly evaluated cognitive behavioral therapy were included. Psychological therapies were associated with improvement in IBS symptoms severity scales (SMD -0.618; 95% CI: -0.853 to -0.383), IBS-Quality of Life (SMD 0.604; 95% CI: 0.440 to 0.768), and abdominal pain (SMD -0.282; 95% CI: -0.562 to -0.001). No statistically significant effect was observed on diarrhea or constipation. Limitations. The trials were at increased risk of bias and the overall sample size was small leading to imprecision. Conclusion. Psychological therapies may improve the quality of life and symptom severity in IBS. The effect size noted is moderate to large and is clinically meaningful.

Cognitive-behavioral therapy for irritable bowel syndrome: a meta-analysis

OBJECTIVE

To establish whether cognitive behavioral therapy (CBT) improves the bowel symptoms, quality of life (QOL) and psychological states of irritable bowel syndrome (IBS) patients.

METHODS

Randomized controlled trials (RCTs) of CBT for adult patients with IBS were searched by using PubMed, Scopus and Web of Science. The standardized mean difference (SMD) with 95% confidence intervals (CIs) of the evidence-based outcome measures of the IBS bowel symptoms, QOL and psychological states at post-treatment and follow-up was calculated. Prespecified subgroup analysis was performed.

RESULTS

Eighteen RCTs satisfied our inclusion criteria. In the subgroup analyses, CBT was more effective in reducing IBS bowel symptoms, QOL and psychological states than waiting list controls at the end of the intervention and short-term follow-up. When compared with controls of basic support and medical treatment, the effect sizes were found to favor CBT for the improvement of IBS bowel symptoms at post-treatment and short-term follow-up, but CBT was not superior to controls in improving QOL and psychological states. When comparing CBT with other psychological controls, the effect sizes were almost non-significant.

CONCLUSIONS

For IBS patients, CBT was superior to waiting list, basic support or medical treatment at the end of treatment but not superior to other psychological treatments. The meta-analysis might be limited by the heterogeneities and small sample sizes of the included studies.

A mixed methods feasibility study to evaluate the use of a low-intensity, nurse-delivered cognitive behavioural therapy for the treatment of irritable bowel syndrome

INTRODUCTION

Irritable bowel syndrome (IBS) is characterised by symptoms such as abdominal pain, constipation, diarrhoea and bloating. These symptoms impact on health-related quality of life, result in excess service utilisation and are a significant burden to healthcare systems. Certain mechanisms which underpin IBS can be explained by a biopsychosocial model which is amenable to psychological treatment using techniques such as cognitive behavioural therapy (CBT). While current evidence supports CBT interventions for this group of patients, access to these treatments within the UK healthcare system remains problematic.

METHODS AND ANALYSIS

A mixed methods feasibility randomised controlled trial will be used to assess the feasibility of a low-intensity, nurse-delivered guided self-help intervention within secondary care gastrointestinal clinics. A total of 60 participants will be allocated across four treatment conditions consisting of: high-intensity CBT delivered by a fully qualified cognitive behavioural therapist, low-intensity guided self-help delivered by a registered nurse, self-help only without therapist support and a treatment as usual control condition. Participants from each of the intervention arms of the study will be interviewed in order to identify potential barriers and facilitators to the implementation of CBT interventions within clinical practice settings. Quantitative data will be analysed using descriptive statistics only. Qualitative data will be analysed using a group thematic analysis.

ETHICS AND DISSEMINATION

This study will provide essential information regarding the feasibility of nurse-delivered CBT interventions within secondary care gastrointestinal clinics. The data gathered during this study would also provide useful information when planning a substantive trial and will assist funding bodies when considering investment in substantive trial funding. A favourable opinion for this research was granted by the Nottingham 2 Research Ethics Committee.

TRIAL REGISTRATION NUMBER ISRCTN

83683687 (http://www.controlled-trials.com/ISRCTN83683687).

Patients with irritable bowel syndrome are more burdened by co-morbidity and worry about serious diseases than healthy controls--eight years follow-up of IBS patients in primary care

Background

Irritable Bowel Syndrome (IBS) is a hidden public health disease that affects up to 20% of the general population. Although co-morbidity can affect diagnose setting and treatment of the disease, there are few studies concerning diagnosed and registered co-morbidity for IBS patients in primary care. The aim of this study was to analyse co-morbidity among IBS-patients compared to age- and sex-matched controls from the general population using data from a county-wide computerized medical record system.

Methods

IBS cases were recruited from three Swedish primary health care centres during a five-years period and controls from the same corresponding geographical areas. Co-morbidity data for IBS-patients and morbidity data for controls were derived from a population-based Health Care Register (HCR) covering all diagnoses in primary as well as hospital care in the region. Odds Ratios with 95% confidence intervals for morbidity in gastro-intestinal and non-gastrointestinal diagnoses for cases with irritable bowel syndrome compared to controls were calculated separately for each gender and diagnosis.

Results

We identified more co-morbidity among IBS patients of both sexes, compared to matched controls in the general population. Patients with IBS were particularly more worried about having a serious disease than their control group. The risk among male IBS-cases to get this latter diagnose was three times higher compared to the male controls.

Conclusions

In this population based case–control study, the analysis of diagnoses from the HCR revealed a broad spectrum of common co-morbidity and significantly more physician-recorded diagnoses among IBS-patients in comparisons to the control group.

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.

Investigation of the effect of military stress on the prevalence of functional bowel disorders

AIM: To investigate the morbidity of functional bowel disorders (FBD) under military stress conditions in order to lay foundations for the prevention and treatment of this disease.

METHODS: Four hundred and fifty-seven soldiers who were assigned to specified services and 471 soldiers who were assigned to routine services were enrolled using cluster sampling, with the latter as a control group. They were surveyed using the Rome III FBD standard questionnaire. The FBD symptom questionnaire included FBD-related symptoms, severity, duration or attack time, and accompanying symptoms.

RESULTS: The morbidity of the military stress group (14.6%) was significantly higher than in the control group (9.98%) (χ² = 4.585, P < 0.05). The incidence of smoking, abdominal pain and acid regurgitation (χ² = 4.761, P < 0.05) as well as the ZUNG anxiety/depression scores (χ² = 7.982, P < 0.01) were also significantly higher in the military stress group compared with the control group. ZUNG anxiety (χ² = 11.523, P < 0.01) and depression (χ² = 5.149, P < 0.05) scores were higher in the FBD group compared with the non-FBD group. The differences in the ZUNG self-rated anxiety and depression scales between the 2 groups were statistically significant (χ² = 14.482, P < 0.01 and χ² = 6.176, P < 0.05).

CONCLUSION: The morbidity of FBD was higher under military stress conditions.

Anxiety and depression in various functional gastrointestinal disorders: do differences exist?

OBJECTIVE

To examine the differences in the prevalence and severity of anxiety and depression in patients with functional dyspepsia (FD), nonerosive reflux disease (NERD), irritable bowel syndrome (IBS) and healthy controls.

METHODS

Consecutive patients undergoing an index endoscopic examination for various symptoms were interviewed. All the three functional gastrointestinal disorders (FGIDs) were diagnosed according to the Rome III criteria. Anxiety and depression were diagnosed using a locally validated version of the hospital anxiety and depression scale.

RESULTS

A total of 248 patients were recruited (62 in FD, NERD, IBS and control groups each) with no differences in the basic characteristics. There was a higher prevalence of anxiety and depression in FD, NERD and IBS groups than that in the control group (43.5%, 45.2% and 67.7% vs 14.5%, P<0.001; and 22.6%, 33.9% and 38.7% vs 6.5%, P<0.0001). Using the cut-off score (>8) for anxiety or depression, IBS patients had a higher rate of anxiety than FD (P=0.01) and NERD (P=0.02), while no significant differences in depression rates were observed among all three groups.

CONCLUSION

[corrected] Anxiety is more common in patients with IBS than in those with FD and NERD, indicating a possible causal link in the former.

Irritable bowel syndrome treatment: cognitive behavioral therapy versus medical treatment

INTRODUCTION

The study aims to investigate two kinds of treatment in patients suffering from irritable bowel syndrome (IBS) and consequently compares its efficacy on improving the symptoms and mental health of patients; one with just medical treatment and another through a combination of psychotherapy and medical treatment.

MATERIAL AND METHODS

Applying general sampling, 50 IBS patients were selected from among those who used to refer to a Gastroenterology Clinic. After physical and mental evaluations based on ROME-II scale and SCL-90-R questionnaires, the subjects were randomly superseded into: the control group with medical treatment and, the case group with a combination of medical and psychological treatments. The acquired data were then analyzed through t-test and Mann-Whitney U-test.

RESULTS

The findings show that the mental health of patients receiving cognitive behavioral therapy along with the medical treatment was higher than those of the control group at post-test level. It was observed that the therapy reduces the disability caused by IBS. Comparatively, while the cognitive therapy and medical treatments cured 80% of the patients, those receiving cognitive therapy alone showed an extensive reduction of symptoms.

CONCLUSIONS

Considering the role of cognitive behavioral therapy, it is therefore recommend that such patients be managed by a combined team of gastroenterologists and psychologists.

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.

Effect of self-management intervention on cortisol and daily stress levels in irritable bowel syndrome

Self-management programs that include cognitive behavioral strategies have been shown to improve gastrointestinal (GI) symptoms, psychological distress, and quality of life (QoL) in persons with irritable bowel syndrome (IBS). However, less is known about the physiological impact of such a change. As part of a randomized controlled trial using a comprehensive self-management (CSM) intervention (n = 126) compared to usual care (UC; n = 62), cortisol levels were measured in 4 weekly first morning urine samples at baseline and at 3-, 6-, and 12-month follow-up. In addition, diary (28 days) ratings of stress were recorded at baseline, 3, 6, and 12 months. The omnibus test of all three outcome times showed no differences in urine cortisol levels between the CSM and UC groups (p = .400); however, at 3 months the CSM group had significantly higher cortisol levels than the UC group (p = .012). The CSM group reported lower daily stress levels (p = .046 from the omnibus test of all 3 time points) than the UC group, with the effect getting stronger over time. Despite marked improvements in reported stress and previously reported GI and psychological distress symptoms at later follow-ups, the CSM program did not reduce urine cortisol levels in adults with IBS. These results suggest that the first-void urine cortisol levels are not reflective of self-reported daily stress in this patient population.

Intervening on cognitions and behavior in irritable bowel syndrome: A feasibility trial using PDAs

OBJECTIVE

Irritable bowel syndrome (IBS) is a common, chronic, and often disabling disorder. Cognitive-behavioral therapy (CBT) has been shown to be effective in alleviating IBS symptoms. The aim of this study was to establish the feasibility and the efficacy of a cognitive-behavioral e-intervention using personal digital assistants (PDAs) on the self-management of IBS patients.

METHODS

A feasibility trial was conducted with 38 control group patients receiving standard care and 37 intervention group patients receiving standard care supplemented with a 4-week CBT intervention on PDAs. All patients fulfilled the diagnostic Rome III criteria for IBS. At baseline, 4-week, and 3-month follow-up, patients' abdominal pain, dysfunctional cognitions, IBS quality of life, and pain catastrophizing thoughts were assessed using written questionnaires.

RESULTS

Between-group comparisons between baseline and 4 weeks showed more overall quality of life improvement, more improvement in catastrophizing thoughts, and more pain improvement in the intervention group. Only improvement in catastrophizing thoughts persisted in the long-term. No significant differences between groups were found for dysfunctional cognitions. As all 37 intervention group patients completed the intervention and completed diaries three times a day for 4 weeks, the e-health intervention seems feasible.

CONCLUSIONS

A cognitive-behavioral intervention on pocket-type computers appears feasible and efficacious for improving IBS-related complaints and cognitions in the short-term. The intervention group improved on several aspects, but most on catastrophizing thoughts, and these improvements even persisted after 3 months. Future studies should focus on unravelling the effective components of this innovative e-health intervention.

Pathways connecting cognitive behavioral therapy and change in bowel symptoms of IBS

OBJECTIVE

A single previous paper on this topic found a direct pathway between cognitive behavioral therapy (CBT) and an irritable bowel syndrome (IBS) global symptom score. This is controversial since under the biopsychosocial model, the expectation is that CBT's effect would be mediated by mood. Using more sensitive bowel symptom scales and measurements at additional time points, we aimed to compare the relative strengths of direct pathways between CBT and change in IBS symptoms and indirect pathways that operate via mood state using structural equation modeling.

METHODS

Our data set included 105 people with Rome I IBS randomized to individual CBT (n=34), relaxation therapy (n=36), and usual medical care (n=35). The primary outcome was defined as adequate relief of IBS symptoms in terms of the distress, frequency, and impairment according to the Bowel Symptom Severity Scale. Outcomes in functional status (according to the 36-item Short-Form Health Survey) and psychological status (Hospital Anxiety and Depression Scale) were secondary outcomes.

RESULTS

Our data suggest indirect pathways that operate via mood, most clearly anxiety but to a lesser extent depression. Statistically significant pathways were identified that lead from CBT to change in mood state thence to change in bowel symptoms, followed by further changes in mood then changes in bowel symptoms. Our data provide no evidence of direct effect of CBT on bowel symptoms.

CONCLUSIONS

The present study suggests that CBT may operate via changes in mood state while not ruling out the possibility of direct effects. Our findings do not directly support, but are consistent with, a biopsychosocial model.

Psychopharmacologic and behavioral treatments for functional gastrointestinal disorders

Functional gastrointestinal disorders (FGIDs) are commonly seen gastrointestinal (GI) conditions that are diagnosed using established symptom-based criteria. These disorders that typically defy traditional diagnostic methods based on structural abnormalities have intrigued researchers for several decades. This has led to the emergence of the current discipline of neurogastroenterology or the study of the "brain-gut axis," which is based on dysregulation of neuroenteric pathways as a key pathophysiologic feature of the FGIDs. Psychopharmacologic and behavioral treatments can influence the dysregulation of these pathways, especially at the severe end of the spectrum, and improve the clinical manifestations of these conditions, visceral discomfort or pain and bowel dysfunction. Their actions are mostly at spinal and supraspinal levels with some direct benefits at the level of the gut. Improvements in coping, global distress, and overall quality of life (QOL) have been shown more consistently with these treatments compared with improvement in GI symptoms. A successful approach to patients with these treatments requires a good physician-patient relationship. Strategizing treatments with these modalities is based on recognition of 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.

Clinical trial: short- and long-term benefit of relaxation training for irritable bowel syndrome

BACKGROUND

Psychotherapy is effective in treating irritable bowel syndrome, but the effect of relaxation training, a brief psychological group intervention, is not known.

AIM

To determine the efficacy of relaxation training in a large cohort of irritable bowel syndrome patients.

METHODS

Ninety-eight irritable bowel syndrome patients were included in this randomized controlled trial. Forty-six patients received standard medical care (CON) and 52 received four 90-min sessions of relaxation training in small groups in addition to standard medical care. Irritable bowel syndrome symptom severity, medical consumption and quality of life were assessed at baseline in patients and in 38 healthy controls and evaluated in patients at 3, 6 and 12 months after intervention.

RESULTS

Irritable bowel syndrome symptom severity was significantly reduced in the relaxation training group compared to CON at 3, 6 and 12 months after treatment (time-by-treatment interaction, P = 0.002). The number needed to treat for long-term improvement was 5. Quality of life had improved (general health, P = 0.017; health change, P = 0.05). Frequency of doctor visits was reduced (P = 0.039).

CONCLUSIONS

Relaxation training is a brief group intervention that significantly improves symptom severity, general health perception and medical consumption in irritable bowel syndrome patients immediately after, as well as 6 and 12 months after intervention.

What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ)

Patient education improves clinical outcomes in patients with chronic illness, but little is known about the education needs of patients with IBS.

OBJECTIVES

The objective of this study was to identify: (1) patients perceptions about IBS; (2) the content areas where patients feel insufficiently informed, i.e., "knowledge gaps" about diagnosis, treatment options, etiology, triggers, prognosis, and role of stress; and (3) whether there are differences related to items 1 and 2 among clinically significant subgroups.

METHODS

The IBS-Patient Education Questionnaire (IBS-PEQ) was developed using patient focus groups and cognitive item reduction of items. The IBS-PEQ was administered to a national sample of IBS patients via mail and online.

ANALYSIS

Frequencies of item endorsements were obtained. Clinically relevant groups, (a) health care seekers or nonhealth care seekers and (b) users or nonusers of the Web, were identified and grouped as MD/Web, MD/non-Web, and non-MD/Web.

RESULTS

1,242 patients completed the survey (371 via mail and 871 online), mean age was 39.3 +/- 12.5 yr, educational attainment 15 +/- 2.6 yr, 85% female, IBS duration 6.9 +/- 4.2 yr, 79% have seen an MD for IBS in the last 6 months, and 92.6% have used the Web for health information. The most prevalent IBS misconceptions included (% of subjects agreeing with the statement): IBS is caused by lack of digestive enzymes (52%), is a form of colitis (42.8%), will worsen with age (47.9%), and can develop into colitis (43%) or malnutrition (37.7%) or cancer (21.4%). IBS patients were interested in learning about (% of subjects choosing an item): (1) foods to avoid (63.3%), (2) causes of IBS (62%), (3) coping strategies (59.4%), (4) medications (55.2%), (5) will they have to live with IBS for life (51.6%), and (6) research studies (48.6%). Patients using the Web were better informed about IBS.

CONCLUSION

(1) Many patients hold misconceptions about IBS being caused by dietary habits, developing into cancer, colitis, causing malnutrition, or worsening with age; (2) patients most often seek information about dietary changes; and (3) educational needs may be different for persons using the internet for medical information.

How does cognitive behavior therapy for irritable bowel syndrome work? A mediational analysis of a randomized clinical trial

BACKGROUND AND AIMS

Although multiple clinical trials support the efficacy of psychological treatments for reducing irritable bowel syndrome (IBS) symptoms, the mechanisms responsible for symptomatic improvement are unknown. One hypothesis is that psychological treatments work by alleviating comorbid psychological distress implicated in the worsening of bowel symptoms and quality of life. An alternative hypothesis assumes that changes in distress are not strictly a cause but a consequence of IBS that will decrease with symptomatic improvement.

METHODS

We evaluated these 2 hypotheses by applying structural equation modeling (SEM) to the data set of a large number (n = 147) of Rome II diagnosed participants randomized to CBT, psychoeducation, or wait list. Per Rome guidelines, the primary end point was global improvement of gastrointestinal (GI) symptoms measured 2 weeks after a 10-week regimen. Secondary end points were distress and quality of life (QOL).

RESULTS

SEM analyses lend support to a model in which CBT is associated with improvements in IBS symptoms, but that therapeutic gains do not depend on changes in patients' overall level of psychological distress. Symptom severity, but not clinical status (pain catastrophizing, predominant bowel habits, symptom duration, abuse, diagnosable psychiatric disorder) or relevant sociodemographic variables (eg, gender, age), moderated treatment outcome.

CONCLUSION

CBT has a direct effect on global IBS symptom improvement independent of its effects on distress. Improvement in IBS symptoms is associated with improvements in the QOL, which may lower distress. Symptom improvements are not moderated by variables reflecting the mental well-being of IBS patients.

Is there a benefit from intensified medical and psychological interventions in patients with functional dyspepsia not responding to conventional therapy?

AIM

In a prospective randomized, controlled trial, to compare the long-term outcome of intensive medical therapy (with or without cognitive-behavioural or muscle relaxation therapy) vs. standard medical therapy in patients with refractory functional dyspepsia (FD), referred to a tertiary referral medical center.

METHODS

A total of 100 consecutive FD patients were allocated to a standardized symptom-oriented 4 month therapy (SMT, n = 24), intensive medical therapy (IMT, medical therapy with testing-for and targeting-of abnormalities of motor-and-sensory function, n = 28) or IMT plus psychological interventions (either progressive-muscle relaxation (IMT-MR, n = 20) or cognitive-behavioural therapy (IMT-CBT, n = 28). The symptom intensity (SI) and health-related quality-of-life (HRQoL) after 12 months were prespecified primary outcome parameters.

RESULTS

After 12 months, significantly greater improvement of SI occurred in patients with IMT-all (with or without psychological interventions) compared with SMT (P < 0.025 vs. IMT-all). IMT, IMT-MR and IMT-CBT alone also resulted in significantly better improvement of the primary outcome parameters (P all < 0.025 vs. SMT). HRQoL significantly improved in all groups with intensive medical therapy but not standard medical therapy. Differences between intensive medical therapy-all and standard medical therapy were not significant. Concomitant anxiety and depression was improved significantly by IMT-CBT (vs. SMT) but not other treatments.

CONCLUSIONS

In FD patients with refractory symptoms, intensified medical management involving function testing and psychological intervention yields superior long-term-outcomes. Additional CBT may be effective for the control of concomitant anxiety and depression.

Cognitive-behavioral hypnotherapy in the treatment of irritable-bowel-syndrome-induced agoraphobia

There are a number of clinical reports and a body of research on the effectiveness of hypnotherapy in the treatment of irritable bowel syndrome (IBS). Likewise, there exists research demonstrating the efficacy of cognitive-behavioral therapy (CBT) in the treatment of IBS. However, there is little written about the integration of CBT and hypnotherapy in the treatment of IBS and a lack of clinical information about IBS-induced agoraphobia. This paper describes the etiology and treatment of IBS-induced agoraphobia. Cognitive, behavioral, and hypnotherapeutic techniques are integrated to provide an effective cognitive-behavioral hypnotherapy (CBH) treatment for IBS-induced agoraphobia. This CBH approach for treating IBS-induced agoraphobia is described and clinical data are reported.

Changes of psychosocial factors, enteric mucosal mast cells and 5-hydroxytryptamine in irritable bowel syndrome

AIM: To explore the roles of psychosocial factors, enteric mucosal mast cells (MC) and 5-hydroxytryptamine (5-HT) in the pathogenesis of irritable bowel syndrome (IBS).

METHODS: Hamilton anxiety scale (HAMA) and Hamilton depression scale (HAMD) were used to evaluate the psychosocial status of 27 IBS patients and controls. Immunohistochemistry was used to examine the number of mucosal MC in ileocecal junction (ICJ), and the content of mucosal 5-HT in ICJ was detected by high-performance liquid chromatography (HPLC) with an electrochemical detector. The relationship among the scores of HAMA and HAMD, the number of MC and the concentration of 5-HT were analyzed.

RESULTS: The scores of HAMA (18.26 ± 6.23) and HAMD (20.93 ± 6.96) in IBS patients were significantly higher than those in the controls (9.15 ± 4.91, 9.89 ± 5.31) (P < 0.05). The number of mucosal MC and the percentage of degranulated MC in ICJ were significantly higher in patients with constipation predominant IBS (C-IBS) (22.1 ± 6.5/HP, 35.4% ± 7.1%) and diarrhea-predominant IBS (D-IBS) (28.4 ± 7.3/HP, 42.3% ± 10.1%) than those in the controls (15.6 ± 6.9/HP, 24.8% ± 7.2%) (P < 0.05), and they were also significantly higher in D-IBS patients than those in C-IBS patients (P < 0.05). The concentration of ileocecal mucosal 5-HT in C-IBS (2669 ± 920 ng/g) and D-IBS (2628 ± 906 ng/g) patients was markedly higher than that in the controls (1893 ± 984 ng/g) (P < 0.05), and it was not significantly different between D-IBS and C-IBS patients (P > 0.05). The scores of HAMA and HAMD were positively correlated with the number of MC (r = 0.784, 0.711) and the percentage of degranulated MC (r = 0.842, 0.860) in ICJ mucosa of IBS patients (P < 0.01), but not with the concentration of mucosal 5-HT (P > 0.05). The concentration of mucosal 5-HT was not correlated with the number of mucosal MC and the percentage of degranulated MC (P > 0.05).

CONCLUSION: IBS patients show the abnormal psychosocial status, increased number of MC, elevated percentage of degranulated MC and enhanced 5-HT in ICJ. The abnormal psychosocial factors are correlated with the increased number and degranulation of mucosal MC.

Arzneimitteltherapie des Reizdarmsyndroms

The therapy of patients with irritable bowel syndrome (IBS) is often challenging, especially if a broad spectrum of symptoms is present and trigger factors, such as the influence of diet or stress, are lacking. Current pathogenetic concepts propose central or peripheral alterations that cause disturbed gastrointestinal function (motility, visceral sensitivity) and subsequent symptoms. These alterations are possibly related to psychological (stress, depression, anxiety) and biological (post-infectious residuals, micro-inflammation) influences. Since no universally effective medical treatment is available to treat the causes of the disease, standard medical therapy is symptom directed (especially for pain, constipation and diarrhoea). In addition to well established drugs (like spasmolytics, opioids and laxatives), newly developed compounds including those with other primarily indications (e.g. antidepressants) are available for highly differentiated individualized therapies. New medical approaches which are currently undergoing evaluation, promise further progress in the treatment of IBS.

Physical and psychological co-morbidity in irritable bowel syndrome: a matched cohort study using the General Practice Research Database

BACKGROUND

Irritable bowel syndrome is a common problem known to have a complex relationship with psychological disorders and other physical symptoms. Little information, however, is available concerning physical and psychological comorbidity in irritable bowel syndrome patients studied over an extended period.

AIM

To evaluate physical and psychological morbidity 2 years before and during 6 years after the time of diagnosis in incident cases of irritable bowel syndrome and control subjects.

METHODS

A matched cohort study was implemented in 123 general practices using the General Practice Research Database. Irritable bowel syndrome cases (n = 1827) and controls (n = 3654) were compared for 2 years before and 6 years after diagnosis.

RESULTS

The age-standardized incidence of irritable bowel syndrome in patients over 15 years of age was 1.9 per 1,000 in men and 5.8 per 1,000 in women. From 2 years before the date of diagnosis, more irritable bowel syndrome cases (13%) than controls (5%) consulted with depression or were prescribed antidepressant drugs. Consultation and prescription rates for anxiety were also higher before diagnosis, and both anxiety and depression remained prevalent up to 6 years after diagnosis. Asthma, symptoms of urinary tract infection, gall-bladder surgery, hysterectomy and diverticular disease were recorded more frequently in irritable bowel syndrome patients, who were also more likely than controls to be referred to hospital.

CONCLUSIONS

People who are diagnosed with irritable bowel syndrome experience more anxiety and depression and a range of physical problems, compared with controls; they are more likely to be referred to hospital.

Systematic review: the efficacy of treatments for irritable bowel syndrome--a European perspective

BACKGROUND

Irritable bowel syndrome (IBS) is a common, chronic disorder, characterized by abdominal pain/discomfort, bloating and altered bowel habit.

AIM

To conduct a systematic evidence-based review of pharmacological therapies currently used, or in clinical development, for the treatment of IBS in Europe. The safety and tolerability of these therapies are the subject of an accompanying review.

METHODS

A literature search was completed for randomized controlled studies which included adult patients with IBS and an active or placebo control, assessed IBS symptoms, and were published in English between January 1980 and June 2005. The level of evidence for efficacy was graded according to the quality of the trial design and the study outcome.

RESULTS

There is some evidence for improvement of individual IBS symptoms with antidiarrhoeals (diarrhoea), antispasmodics (abdominal pain/discomfort), bulking agents (constipation), tricyclic antidepressants (abdominal pain/discomfort) and behavioural therapy. In contrast, there is strong evidence for the improvement of global IBS symptoms with two new serotonergic agents: the 5-HT4 selective agonist tegaserod (IBS with constipation) and the 5-HT3 antagonist alosetron (IBS with diarrhoea). Further data are required for the 5-HT3 antagonist, cilansetron, and the mixed 5-HT3 antagonist/5-HT4 agonist renzapride before their utility in IBS can be appraised.

CONCLUSIONS

There is limited evidence for the efficacy, safety and tolerability of therapies currently available in Europe for the treatment of IBS. Overall, there is an absence of pharmacological agents licensed specifically for the treatment of IBS subtypes, and new agents are awaited in Europe that will allow changes in clinical practice to focus on and improve global IBS symptoms.

An international study of irritable bowel syndrome: Family relationships and mind-body attributions

Irritable bowel syndrome (IBS) is a functional gastrointestinal illness, characterized by potentially debilitating symptoms without pathologic findings, often associated with psychological conditions. Little is known about the psychosocial aspects of this condition on an international scale. A total of 239 patients in eight countries were given a series of psychological and medical questionnaires, including IBS activity, relationships with significant others, beliefs regarding the etiology of symptoms, and assessment of quality of life. There were highly significant associations between IBS severity and all other measures. Symptoms were worse if relationship conflict was high and if attributions about illness were physiological rather than psychological. Symptoms were less severe if relationship depth and support were high, and illness was viewed as psychological. Implications for treatment are discussed.

Psychosocial aspects of the functional gastrointestinal disorders

This report reviews recent research on the psychosocial aspects of the functional gastrointestinal disorders (FGIDs). A review and evaluation of existing literature was conducted by a multidisciplinary committee of experts in this field. This report is a synopsis of a chapter published in the Rome III book. The committee reached consensus in finding considerable evidence supporting the association between psychological distress, childhood trauma and recent environmental stress, and several of the FGIDs but noted that this association is not specific to FGIDs. There is also considerable evidence that psychosocial variables are important determinants of the outcomes of global well-being, health-related quality of life, and health care seeking. In line with these descriptive findings, there is now increasing evidence that a number of psychological treatments and antidepressants are helpful in reducing symptoms and other consequences of the FGIDs in children and adults. The FGIDs are a result of complex interactions between biological, psychological, and social factors, and they can only be treated satisfactorily when all these factors are considered and addressed. Therefore, knowledge about the psychosocial aspects of FGIDs is fundamental and critical to the understanding, assessment, and treatment of these disorders. More extensive physician training is needed if these aspects of treatment are to be used effectively and widely in clinical practice.

Functional abdominal pain syndrome

Functional abdominal pain syndrome (FAPS) differs from the other functional bowel disorders; it is less common, symptoms largely are unrelated to food intake and defecation, and it has higher comorbidity with psychiatric disorders. The etiology and pathophysiology are incompletely understood. Because FAPS likely represents a heterogeneous group of disorders, peripheral neuropathic pain mechanisms, alterations in endogenous pain modulation systems, or both may be involved in any one patient. The diagnosis of FAPS is made on the basis of positive symptom criteria and a longstanding history of symptoms; in the absence of alarm symptoms, an extensive diagnostic evaluation is not required. Management is based on a therapeutic physician-patient relationship and empirical treatment algorithms using various classes of centrally acting drugs, including antidepressants and anticonvulsants. The choice, dose, and combination of drugs are influenced by psychiatric comorbidities. Psychological treatment options include psychotherapy, relaxation techniques, and hypnosis. Refractory FAPS patients may benefit from a multidisciplinary pain clinic approach.

Chronic abdominal pain of functional origin in children

Many future investigations into FGIDs are needed. These should focus on refining and validating the Rome diagnostic criteria, investigating possible biologic markers of these disorders, elucidating the role of the visceral afferent dysfunction or reflex motor responses that lead to symptoms, searching for new pathogenic factors (eg, corticotrophin-releasing factor), and evaluating therapies in prospective controlled trials. To tackle this challenging group of disorders successfully, there must be a broad collaboration among basic scientists, clinical investigators, physicians, psychologists, and practitioners of alternative and complementary medicine to develop and evaluate improved therapies. In the meantime, it is our duty as practitioners to keep updated and receptive to the needs of patients and families to reduce patient suffering, improve functioning, and control the costs to society.

Cerebral processing of auditory stimuli in patients with irritable bowel syndrome

AIM: To determine by brain functional magnetic resonance imaging (fMRI) whether cerebral processing of non-visceral stimuli is altered in irritable bowel syndrome (IBS) patients compared with healthy subjects. To circumvent spinal viscerosomatic convergence mechanisms, we used auditory stimulation, and to identify a possible influence of psychological factors the stimuli differed in their emotional quality.

METHODS: In 8 IBS patients and 8 controls, fMRI measurements were performed using a block design of 4 auditory stimuli of different emotional quality (pleasant sounds of chimes, unpleasant peep (2000 Hz), neutral words, and emotional words). A gradient echo T2*-weighted sequence was used for the functional scans. Statistical maps were constructed using the general

linear model.

RESULTS: To emotional auditory stimuli, IBS patients relative to controls responded with stronger deactivations in a greater variety of emotional processing regions, while the response patterns, unlike in controls, did not differentiate between distressing or pleasant sounds. To neutral auditory stimuli, by contrast, only IBS patients responded with large significant activations.

CONCLUSION: Altered cerebral response patterns to auditory stimuli in emotional stimulus-processing regions suggest that altered sensory processing in IBS may not be specific for visceral sensation, but might reflect

generalized changes in emotional sensitivity and affective reactivity, possibly associated with the psychological comorbidity often found in IBS patients.

Antidepressants and cognitive-behavioral therapy for symptom syndromes

Somatic symptoms are common in primary care and clinicians often prescribe antidepressants as adjunctive therapy. There are many possible reasons why this may work, including treating comorbid depression or anxiety, inhibition of ascending pain pathways, inhibition of prefrontal cortical areas that are responsible for "attention" to noxious stimuli, and the direct effects of the medications on the syndrome. There are good theoretical reasons why antidepressants with balanced norepinephrine and serotonin effects may be more effective than those that act predominantly on one pathway, though head-to-head comparisons are lacking. For the 11 painful syndromes review in this article, cognitive-behavioral therapy is most consistently demonstrated to be effective, with various antidepressants having more or less randomized controlled data supporting or refuting effectiveness. This article reviews the randomized controlled trial data for the use of antidepressant and cognitive-behavior therapy for 11 somatic syndromes: irritable bowel syndrome, chronic back pain, headache, fibromyalgia, chronic fatigue syndrome, tinnitus, menopausal symptoms, chronic facial pain, noncardiac chest pain, interstitial cystitis, and chronic pelvic pain. For some syndromes, the data for or against treatment effectiveness is relatively robust, for many, however, the data, one way or the other is scanty.

Investigating placebo effects in irritable bowel syndrome: a novel research design

Little is known about placebo effects with scientific precision. Poor methodology has confounded our understanding of the magnitude and even the existence of the placebo effect. Investigating placebo effects presents special research challenges including: the design of appropriate controls for studying placebo effects including separating such effects from natural history and regression to the mean, the need for large sample sizes to capture expected small effects, and the need to understand such potential effects from a patient's perspective. This article summarizes the methodology of an ongoing NIH-funded randomized controlled trial aimed at investigating whether the placebo effect in irritable bowel syndrome (IBS) exists and whether the magnitude of such an effect can be manipulated to vary in a manner analogous to "dose dependence." The trial also uses an innovative combination of quantitative and qualitative methods.

Brain activation responses to subliminal or supraliminal rectal stimuli and to auditory stimuli in irritable bowel syndrome

Visceral hypersensitivity in irritable bowel syndrome (IBS) has been associated with altered cerebral activations in response to visceral stimuli. It is unclear whether these processing alterations are specific for visceral sensation. In this study we aimed to determine by functional magnetic resonance imaging (fMRI) whether cerebral processing of supraliminal and subliminal rectal stimuli and of auditory stimuli is altered in IBS. In eight IBS patients and eight healthy controls, fMRI activations were recorded during auditory and rectal stimulation. Intensities of rectal balloon distension were adapted to the individual threshold of first perception (IPT): subliminal (IPT -10 mmHg), liminal (IPT), or supraliminal (IPT +10 mmHg). IBS patients relative to controls responded with lower activations of the prefrontal cortex (PFC) and anterior cingulate cortex (ACC) to both subliminal and supraliminal stimulation and with higher activation of the hippocampus (HC) to supraliminal stimulation. In IBS patients, not in controls, ACC and HC were also activated by auditory stimulation. In IBS patients, decreased ACC and PFC activation with subliminal and supraliminal rectal stimuli and increased HC activation with supraliminal stimuli suggest disturbances of the associative and emotional processing of visceral sensation. Hyperreactivity to auditory stimuli suggests that altered sensory processing in IBS may not be restricted to visceral sensation.

Recognizing and managing patients with irritable bowel syndrome

PURPOSE

To address the diagnosis and clinical management of irritable bowel syndrome (IBS) and provide a discussion of the available serotonergic agents.

DATA SOURCES

Recent studies examining the pathophysiology of IBS.

CONCLUSIONS

Diagnostic testing may be required in the subset of patients with IBS who present with alarm symptoms, or "red flags," suggestive of underlying organic disease. An important role has been suggested for the neurotransmitter serotonin in both gut motility and visceral pain sensitivity.

IMPLICATIONS FOR PRACTICE

A diagnosis of IBS is largely based on symptoms; therefore, effective clinician-patient communication and careful attention to details of patient presentation, history, and physical examination are essential.

Potential future therapies for irritable bowel syndrome: will disease modifying therapy as opposed to symptomatic control become a reality?

Irritable bowel syndrome can remit spontaneously, implying cure is possible. Predictors of good prognosis include a short history, acute onset(possibly postinfective origin), absence of psychological disorders, and resolution of chronic life stressors. Possible-disease modifying treatments with long-lasting effects include diet and anti-inflammatory and psychological treatments. Dietary modifications, which often involve excluding dairy and wheat products, are successful in some patients. Anti-inflammatory treatments have been subjected to one RCT in postinfective IBS without benefit. Probiotics may have benefit in altering bacterial flora and as anti-inflammatory agents, but further trials are needed before they can be recommended. Psychological treatments may produce long-lasting responses. Relaxation therapy appears to have a nonspecific benefit. Psychotherapy has been shown to have long-term benefit and is particularly acceptable to, and effective for, those with overt psychological distress. Hypnotherapy has been shown to be effective in randomized placebo controlled trials and has a sustained effect.

A Critical Review of Cognitive, Behavioral, and Cognitive-Behavioral Therapies for Irritable Bowel Syndrome

Research on controlled evaluations of psychological treatments for IBS is summarized with regards to methodology and outcome, with special attention to differential outcome. There is ample evidence to support the efficacy of various combinations of cognitive and behavioral therapy techniques as well as brief psychodynamic psychotherapy, and hypnotherapy. There has also recently appeared some evidence that is not supportive of each approach. Long-term follow-up, although relatively rare, generally finds the maintenance of initial improvement in IBS symptoms. There is some growing evidence on changes in the putative cognitive mechanisms targeted by the cognitive therapy techniques. More research is needed on these process variables. The field may be ripe for direct comparisons of 2 or more psychological approaches to the IBS treatment.

Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis

This study conducted a systematic review to assess the quality of existing literature on psychological treatments for irritable bowel syndrome and to quantify the evidence for their efficacy. Three independent reviewers (2 from England, 1 from the United States) coded the quality of 32 studies, 17 of which provided data suitable for meta-analysis. Meta-analysis of efficacy data (50% reduction of symptoms) gave an odds ratio of 12 (95% confidence interval = 5.56-25.96) and a number needed to treat of 2. Psychological treatments are, as a class of interventions, effective in reducing symptoms compared with a pooled group of control conditions. Questions regarding the relative superiority of specific psychological treatments and influence of active versus nonspecific treatment effects remain unanswered.

Cognitive behaviour therapy for irritable bowel syndrome

The UK Department of Health states that there is suggestive, although not conclusive, evidence for the efficacy of cognitive behavioural therapy (CBT) in irritable bowel syndrome (IBS) and that CBT should be considered as a treatment option for the syndrome. This paper provides a general introduction to CBT, the principles which underlie it and how they can be applied to IBS. The components of CBT for IBS are described in some detail. Guidelines for gastroenterologists are provided on how these principles can be used to inform their practice and the existing outcome data are reviewed.