Irritable bowel syndrome: Psychotherapy can improve GI symptoms and emotional health
Medical treatment alone has proven disappointing, but psychotherapeutic approaches are showing promise.
For patients with diarrhea-predominant IBS, rectal sensitivity was significantly reduced during hypnosis and after the full course of hypnotherapy, compared with controls (p<0.05). In patients with constipation-predominant IBS, a trend towards normalized rectal sensitivity did not reach statistical significance. The investigators concluded that symptomatic improvement of IBS after hypnotherapy may be related to changes in visceral sensitivity of the colon.16
These investigators later studied changes in distal colonic motility in 18 patients undergoing hypnotherapy for IBS. As the patients’ hypnotically induced anger or excitement increased, colonic motility decreased significantly (p<0.01) The investigators concluded that hypnosis may be a useful tool to investigate the effects of emotion on physiologic function.17
Using more contemporary outcome measures and diagnostic criteria, these investigators later showed that hypnotherapy significantly improved:
- IBS symptoms (abdominal pain and bloating, bowel habit, nausea, flatulence, urinary symptoms, lethargy, backache, and dyspareunia)
- quality of life (psychological and physical well-being, mood, locus of control, and work attitude).
Patients treated with hypnosis also took less time away from work (p = 0.02) and visited their physicians less often (p = 0.056), compared with controls.18
Other hypnosis studies. In the United States, another group randomly assigned 12 patients to gut-directed hypnotherapy or symptom monitoring. Subjects were matched by concurrent psychiatric diagnosis, susceptibility to hypnosis, and demographic features.
In findings similar to those of the Manchester group, primary IBS symptoms (abdominal pain, constipation, and flatulence) of patients who received hypnotherapy improved more than those of controls (p = 0.016). Anxiety, as measured by the Spielberger State-Trait Anxiety Inventory (STAXI), also decreased significantly. Treatment-induced gains were well-maintained 2 months later. No significant correlation was found between initial sensitivity to hypnosis and subsequent response to hypnotherapy. A positive relationship was seen between the presence of psychiatric diagnoses and overall levels of improvement.
This study suggests that hypnotherapy can be useful for treating IBS and can be easily adapted to different clinical settings and treatment populations.19 A similar study using gut-directed hypnotherapy found significant improvement in 27 IBS patients treated with short-term hypnosis, and symptom improvement persisted after treatment.20
Biofeedback
The role of biofeedback in IBS treatment remains ill-defined. To be considered as a treatment option, biofeedback must meet or exceed the benefits being achieved with psychotherapy, hypnotherapy, and other behavioral approaches.
In gastroenterology, biofeedback has been used mainly to treat constipation and specifically for outlet constipation due to pelvic floor dysfunction. Anorectal probes to measure rectal pressure in the resting state and during defecation can reveal a pattern of pelvic floor dysfunction. Studies have demonstrated up to 67% improvement in constipation symptoms using biofeedback. Use of anorectal biofeedback in adults with IBS also appears promising, but more controlled trials are needed.21
Anorectal biofeedback has also been used effectively to treat fecal incontinence in children and adults, achieving success rates of 70% or better. In IBS, however, the benefit of biofeedback is less clear. Studies of multicomponent treatment—combining biofeedback with CBT techniques—suggest improvement rates in the 50 to 60% range. However, these findings need to be compared with other treatments for IBS.
Combination treatment
Medical treatment of IBS is progressing. Antidepressant therapy, particularly using tricyclics, has shown moderate benefit.22 Newer medications such as alosetron and tegaserod, which modulate serotonin metabolism in the gut, have been developed. Alosetron and tegaserod have shown significantly greater efficacy compared with placebo for treatment of women with the diarrhea-predominant and constipation-predominant types of IBS, respectively.
Alosetron was voluntarily withdrawn from clinical use in 2000 because of reports of serious GI events associated with its use, including ischemic colitis in a small number of patients (about 3 women in 1,000). Because of the drug’s efficacy in IBS, however, the FDA recently approved its rerelease with a restricted indication—it is to be used only in women with severe diarrhea-predominant IBS who have not responded to conventional IBS treatment. The drug’s manufacturer also is implementing a risk management plan designed to reduce the potential for serious GI side effects.
Table
PSYCHOTHERAPY AS TREATMENT FOR IRRITABLE BOWEL SYNDROME
| Psychotherapeutic approach | Summary of research results |
|---|---|
| Psychodynamic therapy | Shown to be effective in reducing pain and dysphoric mood5 |
| Interpersonal psychotherapy | Effective in reducing pain, bloating, and health care utilization and improving emotional well-being7 |
| Cognitive-behavioral therapy | Improves coping skills and decreases helplessness and somatization14 |
| Group psychotherapy | Seems to be as efficacious as cognitive-behavioral therapy, with the added efficiency of a group model13 |
| Hypnotherapy | Highly effective for a spectrum of IBS symptoms15 |
| Biofeedback | Not useful for IBS per se, but helpful for pelvic floor dysfunction21 |
| Combination therapy | Emerging as a particularly useful strategy, combining medical and behavioral approaches23 |
Tegaserod, a serotonin-4 receptor (5HT4) agonist, was approved by the FDA in July. It is indicated for short-term treatment of women with IBS whose primary bowel symptom is constipation.
