A biopsychosocial understanding of the irritable bowel syndrome: a review

Antioxidant Capacity and Behavioral Relevance of a Polyphenolic Extract of Chrysanthellum americanum in a Rat Model of Irritable Bowel Syndrome

Chrysanthellum americanum L. (Vatke) is a medicinal plant from the Compositae family used in west-African traditional medicine, known for its flavonoid and saponin richness and for its strong antioxidant potential. In the present study, we assessed the effects of Chrysanthellum americanum polyphenolic extract in the psychological stress-induced rat model of irritable bowel syndrome (IBS), a chronic functional digestive tract disorder marked by immune and inflammatory-related disturbances of central nervous and peripheral intestinal systems, which is often associated with mood disorders including depression and anxiety. Consequently, memory impairment, anxiety and depression behavioral indicators, and cerebral oxidative stress biomarker dynamics were evaluated in a multifactorial heterotypic stress-exposed IBS rats after 6-day gavage with polyphenolic C. americanum extract (100 mg/kg body weight). Y-maze, elevated plus maze, and forced swimming tests were used for assessing behavioral responses. Administration of the extract exhibited significant anxiolytic and antidepressant-like effects coupled with significantly increased temporal lobe antioxidant enzyme specific activity (superoxide dismutase and glutathione peroxidase) and decreased malondialdehyde levels, a well-known lipid peroxidation marker. Furthermore, linear regression statistical analyses showed significant correlations between the oxidative stress parameters and behavioral tests. In conclusion, our results suggest that the administration of Chrysanthellum americanum polyphenolic extract could ameliorate mood and cognitive disturbances related to stress-induced in an IBS rat model. This could be also related to cerebral oxidative stress status attenuation.

Multicenter study of gastroenterologists' ability to identify anxiety and depression in a new patient encounter and its impact on diagnosis

AIM

Although gastroenterologists are frequently exposed to psychopathology few data exist regarding their ability to accurately assess anxiety and depression or the impact of their perceptions of anxiety and depression on diagnostic decisions. The aims of this study were to determine gastroenterologists' ability to correctly identify anxiety and depression in patients with gastrointestinal symptoms and to determine whether gastroenterologist perceptions of anxiety and depression affected postvisit diagnosis.

METHODS

One hundred fifty-nine consecutive patients making their initial visit to 3 university outpatient clinics were evaluated by 38 gastroenterologists and completed Hospital Anxiety and Depression Scale. Gastroenterologists rated their perceptions of patient anxiety and depression on 100-mm visual analog scales and indicated whether they thought the patient was clinically anxious or depressed. On the basis of the gastroenterologists' postvisit diagnosis, patients were entered into functional gastrointestinal disorder (FGID; n=28), symptom-based (SB) diagnosis (n=45), or organic disease (OD; n=86) groups.

RESULTS

Anxiety and depression were present in 40% and 20% of patients, respectively. Gastroenterologists' categorization of patients as having clinically significant anxiety and depression were poor with positive predictive values of 0.52 and 0.26, respectively. Patients perceived as anxious by their gastroenterologist were more than twice as likely to receive a FGID diagnosis.

CONCLUSIONS

Anxiety and depression were prevalent in the study population yet gastroenterologists did not accurately detect these conditions. However, gastroenterologists were more than twice as likely to diagnose patients whom they perceived as anxious as having an FGID, highlighting a need for improved psychosocial assessment in clinical practice and education to diminish misattributions regarding FGID.

Fibromyalgia: a rheumatologic diagnosis?

Fibromyalgia (FM) is a medically unexplained or functional somatic syndrome (FSS). The two classification criteria are chronic widespread pain (CWP) and the finding of 11/18 tender points (TP). FM overlaps and co-occurs with other FSSs, and auxiliary symptoms that are not included in the criteria may be clues to other FSSs. About ten FSSs include chronic fatigue syndrome, myofascial pain syndromes and irritable bowel syndrome. TP do not reflect demonstrable pathology, and are locations where everyone is generally more tender. In FM they are more tender than normal due to lowered pain threshold. High TP counts are associated with the extent of distress or unspecific somatic symptoms in the absence of chronic pain. TP lack validity and should be excluded. CWP and distress are outside the domain of rheumatology, and abnormal mechanisms in FM relate to the central nervous system, as compared to "peripheral" mechanisms studied in rheumatology. FM should not be considered as a rheumatologic condition but rather as part of a broader spectre of FSSs. Patients with FSSs should be considered and treated together across medical specialities by general physicians in primary health care.

Basal and stimulated hypothalamic-pituitary-adrenal axis activity in patients with functional gastrointestinal disorders and healthy controls

OBJECTIVE

The aim of this study was to investigate alterations of pituitary-adrenal activity under both stimulated and unstimulated conditions in patients with functional gastrointestinal disorders.

METHODS

Thirty subjects who fulfilled the Rome Diagnostic Criteria for either irritable bowel syndrome or nonulcer dyspepsia and 24 healthy controls took part in the study. Free salivary morning cortisol and diurnal cortisol profiles were obtained for all subjects. On a second day, a low-dose dexamethasone suppression test was applied. Additionally, in all subjects a corticotropin-releasing hormone (CRH) challenge test was performed.

RESULTS

The results show attenuated unstimulated cortisol levels in patients compared with controls. After CRH challenge, blunted adrenocorticotropic hormone and cortisol responses were observed. These findings suggest lower pituitary and adrenocortical activity in patients with functional gastrointestinal disorders.

CONCLUSION

The observed pituitary-adrenal reactivity in these patients is discussed as a possible consequence of lower adrenocortical activity, possibly resulting in a disinhibition of CRH in the brain.

General practitioners believe that hypnotherapy could be a useful treatment for irritable bowel syndrome in primary care

Background

Irritable bowel syndrome is a common condition in general practice. It occurs in 10 to 20% of the population, but less than half seek medical assistance with the complaint.

Methods

A questionnaire was sent to the 406 GPs listed on the West Sussex Health Authority Medical List to investigate their views of this condition and whether they felt hypnotherapy had a place in its management

Results

38% of general practitioners responded. The achieved sample shared the characteristics of target sample.

Nearly half thought that irritable bowel syndrome (IBS) was a "nervous complaint" and used a combination of "the placebo effect of personal care," therapeutic, and dietary advice. There is considerable divergence in the perceived effectiveness of current approaches. Over 70% thought that hypnotherapy may have a role in the management of patients with IBS; though the majority (68%) felt that this should not be offered by general practitioners. 84% felt that this should be offered by qualified hypnotherapist, with 40% feeling that this should be offered outside the health service.

Conclusions

General practitioners vary in their perceptions of what constitutes effective therapy in IBS. They are willing to consider referral to a qualified hypnotherapist.

Irritable bowel syndrome

Irritable bowel syndrome is a biopsychosocial disorder characterized by dysregulation of intestinal motor, sensory, and central nervous system functions. It is associated with significant disability and health-care costs. The traditional diagnostic approach leads to excessive investigation for many patients. A reductionist approach of focusing on evaluation and treatment of a single mechanism is unlikely to prove effective. Identification of the characteristic symptom pattern is the key to cost-effective management. A strong patient-physician relationship is essential for a successful outcome. Optimal outcome is predicated on an individualized treatment plan that integrates pharmacologic and behavioral modalities.

Irritable bowel syndrome

Within the literature, it appears evident that neither a univariate etiologic model nor a single-agent treatment approach is sufficient to address the many diagnostic, assessment, and therapeutic challenges posed by irritable bowel syndrome (IBS). Various scientific advances have been made over the past 5 years, particularly in the areas of nonpharmacologic management of IBS. However, further collaboration between scientists and clinicians from multiple disciplines is strongly encouraged.

Psychologic Therapies for Irritable Bowel Syndrome

The treatment of patients with irritable bowel syndrome (IBS) is a difficult task, as the results from therapy with pharmacologic agents have been disappointing. Psychologic treatments, in particular cognitive behavior therapy, hypnotherapy, and dynamic psychotherapy have all shown to be effective in the treatment of patients with IBS. Underpinning all these treatments is a clear understanding of a biopsychosocial model of interaction between emotion and gut function in IBS. These psychologic therapies are intended to break the negative feedback loop between emotion and gut function in order to reduce symptoms. Attention to the psychologic issues underlying IBS helps reduce psychosocial factors that maintain the presence of symptoms and inappropriate health-care seeking behavior. There are a number of common elements in the psychologic approaches that can be used in routine clinical practice; these include a detailed assessment, psychoeducation, support, and reassurance.

Empirical findings on the use of hypnosis in medicine: a critical review

Recent changes in health care have been characterized by an increased demand for empirically supported treatments in medicine. Presently, there is moderate support for the integration of hypnotic techniques in the treatment of a number of medical problems. This critical review of the research literature focuses on the empirical research on the effectiveness of hypnotic treatments as adjuncts to medical care for anxiety related to medical and dental procedures, asthma, dermatological diseases, gastrointestinal diseases, hemorrhagic disorders, nausea and emesis in oncology, and obstetrics/gynecology. Wider acceptance of hypnosis as an intervention to assist with medical care will require further research.

Cognitive-behaviour therapy as a treatment for irritable bowel syndrome: a pilot study

OBJECTIVE

The irritable bowel syndrome (IBS) is a chronic and often disabling functional bowel disorder. Psychological treatments, in particular cognitive and behavioural interventions, have been shown to be effective for this disorder. The aim of this study was to test the efficacy of a cognitive-behaviour program.

METHOD

Eight participants (seven female, one male) aged between 24 and 71 years, with a diagnosis of IBS according to the Rome criteria, were recruited from among the gastroenterology outpatients at Nepean Hospital, in Sydney, Australia. Participants were administered pretreatment on measures of psychological function and bowel symptom severity. Following a 2-week baseline period, participants began a structured psychological treatment comprising eight sessions of cognitive-behaviour therapy. Throughout treatment, participants maintained daily records of symptom severity and completed homework assignments to ensure treatment compliance. The pretreatment assessment measures were repeated 1 week post-treatment.

RESULTS

After treatment, five of the eight patients no longer met the Rome diagnostic criteria for IBS. There was no significant reduction in bowel symptom frequency. There were, however, significant improvements in the distress and disability associated with bowel symptoms. Anxiety and depression were also significantly reduced.

CONCLUSIONS

Cognitive-behaviour therapy reduced the distress and disability associated with IBS, but not the frequency of bowel symptoms. This supports the proposed cognitive model for IBS, and cognitive-behaviour therapy appears to have its effect by altering the cognitive response to visceral hypersensitivity.