|
A Leahy and O Epstein
Centre
for Gastroenterology, Royal Free and University College Medical
School, London, UK
Dr. A Leahy MRCP, Gastroenterology Specialist Registrar; Dr. O
Epstein FRCP, Consultant Gastroenterologist.
Correspondence to: Dr. Owen Epstein, Centre for
Gastroenterology, Royal Free Hospital, Pond Street, London NW3 2QG,
UK
Received: 2001-03-20 Accepted:
2001-04-15
Subject
headings: colonic
diseases, functional/therapy; psychotherapy; hypnosis; biofeedback
(psychology); complementary medicine
Leahy
A, Epstein O. Non-pharmacological treatments in the irritable bowel
syndrome. World J Gastroenterol, 2001;7(3):313-316
INTRODUCTION
The irritable bowel syndrome (IBS) is a gastrointestinal
disorder characterised by chronic lower abdominal pain and
disordered defaecation associated with bloating, tenesmus and
extra-intestinal symptoms including urinary frequency, dyspareunia,
fibromyalgia and functional upper gastrointestinal symptoms.
Currently there is no unifying hypothesis which adequately explains
the pathogenesis of the disorder although a number of physiological
and psychological abnormalities have been described. These include
altered visceral sensitivity, abnormal intestinal motility and
abnormalities of cortical processing of afferent stimuli from the
gut. These observations are set against a background of abnormal
psychological profiles and an over representation of negative early
life experiences. Failure to identify the cause of IBS has led to
the development of a range of therapies, some designed to influence
the physical effects of the disorder and others to influence the
psychological features of the syndrome.
Most
IBS patients managed in primary care respond to dietary
modification, conventional pharmacological interventions and
reassurance. However, when considering any therapeutic efficacy in
IBS, it is necessary to weigh the therapeutic effect against the
placebo response rate which has been reported to range from 40%-70%.[1]
Approximately 15% of IBS patients are resistant to medical therapy.
Psychological treatments are usually reserved for these refractory
patients and those who relapse despite an initial response to
medical treatment. Tricyclic antidepressants have been widely used
in IBS and are probably effective through anticholinergic and
analgesic effects rather than antidepressant activity.
Placebo-controlled trials of tricyclics indicate that even at low
doses, they are helpful in the management of abdominal pain and
diarrhoea in IBS[2] .
Over the past two
decades, there have been various attempts to treat IBS using
non-pharmacological approaches. As evidence has accumulated to
support a role for these interventions, both patients and
gastroenterologists have shown increasing interest in exploring this
approach to IBS treatment. In this review we consider the evidence
for psychopathology in IBS and the efficacy of non-pharmacological
interventions.
PSYCHOLOGICAL MORBIDITY IN IBS
From the very first reports of IBS in the medical literature,
psychological factors have been recognised as an important component
of the syndrome. In 1859, the cause for IBS was attributed to
overeating, over-drinking and excess of “sexual or other emotional
excitement, sedentary life, damp or hot atmosphere, and the abuse of
purgatives, but above all aloes”. A “highly excitable condition
of nervous centres” was postulated as the cause of IBS, and in
1892, IBS patients were described as manifesting “hysterical,
hyperchondriacal and neurasthenic personalities”[3].
With the
development of scientific method in medical research, attempts have
been made to provide both qualitative and quantitative measures of
psychological morbidity in IBS. At least ten studies have assessed
the prevalence of psychological disorders in IBS patients[4].
Between 42%-64% of IBS patients meet criteria for a psychiatric
diagnosis compared to a median incidence of 19% in patients with
organic gastrointestinal disease, and 16% in healthy controls. The
most common diagnoses are a generalised anxiety disorder and
depression. There is no unique psychological profile which
characterises IBS. This higher prevalence of psychological
dysfunction in IBS appears to relate only to those sufferers who
seek medical advice. Indeed, the majority of individuals fulfilling
the criteria for IBS never seek medical attention and these
non-consulters have a similar psychological profile to asymptomatic
controls[5-7]. This, in turn has provided evidence that
psychological factors rather than severity of symptoms influences
the decision to seek medical attention. Most IBS consulters have
been shown to have experienced negative early life experiences and
heightened anxiety about health status. These observations suggest
that management in primary and secondary care should focus not only
on symptoms, but also on those psychological factors which have
caused the patient to seek medical advice.
There
is strong evidence that stress is an important factor in the
pathogenesis of IBS[8]. Stress of major “life
events”, rather than the stress of everyday living, has been
implicated as a trigger factor in many patients. In addition,
patients often recognise that periods of excessive stress exacerbate
their symptoms. In patients with IBS there is good evidence that
stressful life events are more frequent, and the effects on GI
function more profound, than controls[9,10]. It is
against this background of anxiety, depression, stress and
consulting behaviour patterns that psychodynamic strategies have
been developed to manage IBS.
PSYCHOTHERAPY IN IBS
Psychotherapy is a treatment that primarily seeks to relieve
symptoms by exploring the patient’s underlying psychological
conflicts and emotional disturbances. The first reported study of
psychotherapy in IBS included 101 patients who were randomized to
medical therapy with or without psychotherapy[11]. The
psychotherapy was delivered over ten sessions and focused on
mechanisms for coping with stress and resolving emotional problems.
Psychotherapy was found to produce a greater improvement in
abdominal pain and bowel dysfunction than medical therapy alone.
Although symptoms were positively influenced, this short term
therapy did not significantly influence the underlying
psychopathology. The authors suggested that this might be explained
by the relatively mild psychological morbidity in their patients, as
the presence of a serious psychological disorder was an exclusion
criteria for the study. This study, although of interest, and often
quoted, has methodological flaws including the decision to exclude
patients with more severe psychological disturbance in whom this
therapy might have been of greater value. In addition, the study did
not include a placebo arm or select placebo non-responders. The
study left it unclear whether the improvement of physical symptom
was a result of the psychotherapy or the considerable attention
invested in the psychotherapy group.
These
pitfalls were addressed by a later study of psychotherapy in IBS
performed by Guthrie et
al[12].
One hundred and two patients refractory to previous medical
treatment were randomized to receive psychotherapy or supportive
listening. The psychotherapy concentrated on developing a healthy
patient-therapist relationship, recognizing other inter-personal
relationships and their possible role in the patient’s presenting
problems. Psychotherapy was found to be superior to supportive
listening in terms of improving both physical and psychological
symptoms and the improvement in gastrointestinal function correlated
significantly with improved psychological well-being. Excellent
study design and attention to detail has made this study a benchmark
for both pharmacological and non-pharmacological studies in IBS.
BEHAVIORAL THERAPY IN IBS
Behavioral treatment seeks to address and deal with current issues,
anxieties and behavioral patterns rather than indulging in deep
analysis of past experiences. An uncontrolled trial of behavioral
therapy has been reported with a 4 year follow- up[13].
In this study the authors used a combination of progressive muscle
relaxation, thermal biofeedback, cognitive therapy and IBS
education. All but two of the nineteen patients who were available
for long-term follow-up rated themselves as at least 50% improved.
Symptom diaries were used to demonstrate that the therapy resulted
in significant reductions in abdominal pain, diarrhoea, nausea and
flatulence. However, like many studies in IBS, the study was
inadequately controlled. A more carefully controlled trial of
behavioral therapy has been reported in IBS[14].
Forty-two patients were randomly allocated to receive either
conventional medical treatment or behavioural therapy with a nurse
therapist. The therapy concentrated on behaviour modification, bowel
retraining and pain management techniques. It was noted that there
were improvements in a number of physical and psychological
symptoms, but no significant differences was found when the
treatment group was compared with controls. The authors concluded
that their approach to behaviour modification was no more effective
than conventional medical therapy and reassurance.
HYPNOTHERAPY IN IBS
Hypnotherapy is a state of unusual concentration on the suggestions
of the therapist and a willingness to follow their instructions[15]
Whorwell et al have reported well constructed
controlled trials of hypnotherapy in IBS. The technique is focused
around a specific “gut directed” hypnosis protocol where the
patient is taught to assert control over gut function and imagery
whilst in an hypnotic state[16]. Patients are given a
simple account of intestinal smooth muscle physiology and hypnotised
in a standard manner. The patient is then requested to place their
hand on the abdomen and to sense both a positive feeling of
abdominal warmth and increased control over gut function. During
hypnosis, visualisation is also employed, using the analogy of a
gently flowing river and a gently flowing bowel to reinforce a
positive bowel image.
Whorwell’s
initial study randomised thirty refractory IBS patients to seven
sessions of either hypnotherapy or psychotherapy. When compared to
psychotherapy, hypnotherapy was found to have a greater impact on
abdominal pain, bowel habit, abdominal distension and general
well-being. It should be noted, however, that the response rate in
the psychotherapy group was much lower than those reported from
other centres[11,12]. Further experience of gut directed
hypnotherapy has been reported in 250 IBS patients indicating an
overall response rate of approximately 80%. Factors predicting a
less satisfactory response to hypnosis includes atypical symptoms,
older age and more profound psychological disturbance[17].
Two
other independent groups have obtained similar results using gut
directed hypnotherapy[18,19]. Both these studies were
uncontrolled but do appear to support the value of hypnotherapy in
IBS. In addition, it has been reported that hypnotherapy in groups
of up to eight patients is as effective as individual therapy[18].
Further support for the effectiveness of hypnotherapy in IBS derives
from studies on the effect of hypnotherapy on gut function. In two
separate studies, hypnotherapy has been reported to reduce rectal
sensitivity and colonic motility[20,21].
RELAXATION THERAPY IN IBS
Recognition that stress is a major factor in IBS has provided a
basis to explore stress management as a therapy in these patients.
Stress management has been compared to conventional therapy in a
trial of 35 patients[22]. A physiotherapist delivered a
median of six sessions aimed at recognizing the relationship between
symptoms and stress, and teaching relaxation exercises. IBS symptoms
were relieved in two-thirds of patients receiving stress therapy,
and only a small number of patients receiving conventional therapy.
A small pilot study also found that teaching progressive muscle
relaxation was effective in improving gastrointestinal symptoms[23].
Whilst these studies are encouraging, larger controlled studies are
required to make a firmer statement on the potential of relaxation
therapy in IBS.
BIOFEEDBACK THERAPY IN IBS
Biofeedback is a behavioural technique that uses visual or auditory
cues to teach patients to alter physiological responses. With
biofeedback, physiological events which are not normally appreciated
by the patient are sensed by a technological interface and amplified
to give the subject visual or auditory feedback. Patients soon learn
to influence the loop and manipulate these physiological events
thereby modifying organ function. A new form of biofeedback therapy
has been developed and tested in IBS patients[24]. The
biofeedback loop is based on the polygraph (“lie detector”)
which monitors tiny changes in electodermal conductivity occurring
in response to stress and relaxation. Changes in cutaneous
electrical activity are electronically transformed into a
computerised animation of the gut shown on the computer screen. This
animation can be controlled by the patient who learns to manipulate
the computerised representation of bowel movement using a
combination of mental and physical relaxation. In a study of
computer-aided gut directed biofeeback, 40 IBS patients who were
refractory to conventional treatment underwent 4 half-hour
biofeedback sessions. Eighty percent of the patients learned to
achieve progressively deeper levels of relaxation, and in 50%, the
technique was reported helpful in controlling bowel symptoms on
almost every occasion they became troublesome. The relaxation
technique also resulted in significant reductions in global and
bowel symptom scores. A control group was not included as it is not
possible to administer placebo biofeedback but the study was
restricted to treatment refractory patients (ie presumed placebo
non-responders). An independent group has also recently reported
that biofeedback approach is beneficial in managing IBS[25].
In this uncontrolled study, all comers were entered and there was no
attempt to select patients. Sixty patients received biofeedback with
improvements in abdominal pain, urgency of defaecation and global
well-being.
COMPLEMENTARY THERAPY IN IBS
A small open pilot study of acupuncture produced a significant
improvement in general well-being and abdominal bloating[26].
There has not been any large controlled trial assessing any form of
complementary treatment in IBS.
SUMMARY
Over the last two decades evidence has mounted to suggest that
non-pharmacological therapies may be helpful in IBS. Like IBS trials
of pharmacological therapies, the studies are often small and poorly
controlled. The trials designed to account for a high placebo
response rate have either compared non-pharmacological strategies
with conventional treatment, or selected only patients who were
placebo non-responders. There is broad agreement from the few
adequately controlled trials that psychotherapy offers a clear
additional therapeutic benefit over and above medical treatments[12].
Hypnotherapy appears to be particularly potent, and, in expert
hands, produces consistently impressive therapeutic results even in
patients refractory to conventional IBS treatment[17].
Most IBS
patients respond to standard medical treatments. Psychological
strategies are time consuming, labour intensive and generally
unavailable to the relatively large numbers of patients who might
benefit. Consequently, these therapies are best reserved for
selected patients who fail to respond to reassurance and education,
dietary manipulation, antispasmodics and low dose amitriptyline.
Increasingly, patients are expressing a preference for
non-pharmacological treatment strategies. Where resources allow, it
is not unreasonable to offer these patients a psychodynamic approach
as first-line therapy. Ideally, the gastroenterologist should have
access to a range of treatment strategies including diet, drugs,
psychotherapy, hypnotherapy, relaxation therapy and biofeedback. New
approaches such as gut directed, computer-aided biofeedback are
particularly attractive as, unlike the interpersonal therapies, this
mode of biofeedback does not require highly trained therapists and
can be self-administered[24]. Whatever the choice of
non-pharmacological therapy, there is evidence that both the doctor
and patient can expect symptom improvement, especially when
conventional medical measures have failed.
REFERENCES
1 Pace F, Coremans G, Dapoigny M, Muller-Lissner,
Smout A, Stockbruegger RW, Whorwell PJ. Therapy of irritable bowel
syndrome-an
overview. Digestion, 1995;56:433-442
2 Drossman DA, Whitehead WE, Camilleri M.
Irritable bowel syndrome: A technical review for practice guideline
development.
Gastroenterology, 1997;112:2120-2137
3 Osler W. Principles and practice of Medicine.
New York: Appleton, 1892
4 Drossman DA, Creed FH, Fava GA, Olden KW,
Patrick DL, Toner BB, Whitehead WE. Psychosocial aspects of the
functional
gastrointestinal disorders. Gastroenterol Int, 1995;8:47-90
5 Whitehead WE, Bosmajian L, Zonderman AB, Costa
PTJ, Schuster MM. Symptoms of psychologic distress associated
with
irritable bowel syndrome. Camparison of community and medical
clinic samples. Gastroenterology,
1988;95:709-714
6 Drossman DA, McKee DC, Sandler RS, Mitchell CM,
Cramer EM, Lowman BC, Burger AL. Psychosocial factors in the
irritable
bowel syndrome: a multivariate study of patients and
nonpatients with irritable bowel syndrome.
Gastroenterology,
1988;95:701-708
7 Sandler RS, Drossman DA, Nathan HP, Mckee DC.
Symptom complaints and health care seeking behaviour in
subjects
with
bowel dysfunction. Gastroenterology, 1984;87:314-318
8 Creed FH, Craig T, Farmer RG. Functional
abdominal pain, psychiatric illness and life events. Gut,
1988;29:235-242
9 Mendeloff AI, Monk M, Siegel CI, Lilienfeld A.
Illness experience and life stresses in patients with irritable
colon and
with
ulcerative colitis: an epidemiologic study of ulcerative
colitis and regional enteritis in Baltimore, 1960-1964.
N
Engl J Med, 1970;282:14
10 Whitehead WE, Crowell MD, Robinson JC, Heller BR, Schuster
MM. Effects of stressful life events on bowel symtoms:
Subjects
with irritable bowel syndrome compared with subjects without
bowel dysfunction. Gut, 1992;33:825
11 Svedlund J, Sjodin I, Ottosson JO, Dotevall G. Controlled
study of psychotherapy in irritable bowel syndrome. Lancet,
1983;ii:589-591
12 Guthrie E, Creed F, Dawson D, Tomenson B. A randomised
controlled trial of psychotherapy in patients with refractory
irritable
bowel syndrome. Br J Psychiatry, 1993;163:315-321
13 Schwartz SP, Taylor AE, Scharf L, Blanchard EB.
Behaviourally treated irritable bowel syndrome patients: a four
year
follow
up. Behav Res Ther,
1990;28:331-335
14 Corney RH, Stanton R, Newell R, Clare A, Fairclough P.
Behavioural psychotherapy in the treatment of irritable bowel
syndrome.
J Psychosom Res, 1991;35:461-469
15 Hill O. Contemporary hypnotherapy. B J Hosp Med,
1993;50:9-13
16 Whorwell PJ, Prior A, Colgan SM. Hypnotherapy in severe
irritable bowel syndrome: further experience. Gut,
1987;28:423-425
17 Whorwell PJ. Use of hypnotherapy in gastrointestinal
disease. Br J Hosp Med, 1991;45:27-29
18 Harvey RF, Hinton RA, Gunary RM, Barry RE. Individual and
group hypnotherapy in treatment of refractory irritable
bowel
syndrome. Lancet, 1989;i:424-425
19 Vidakovic-Vukic M. Hypnotherapy in the treatment of
irritable bowel syndrome: methods and results in Amsterdam.
Scand
J Gastroenterol, 1999;(Suppl 230):49-51
20 Whorwell PJ, Houghton LA, Taylor EE, Maxton DG.
Physiological effects of emotion: assessment via hypnosis. Lancet,
1992;346:69-70
21 Houghton LA, Larder S, Lee R, Gonsalkorale WM, Whelan V,
Randles J, Cooper P, Cruickshanks P, Miller V,
Whorwell
PJ. Gut focused hypnotherapy
normalises rectal hyper-sensitivity in patients with irritable bowel
syndrome.
Gut,1999;44(Suppl
1):A133
22 Shaw G, Srivastava ED, Sadlier M, Swann P, James JH, Rhodes
J. Stress management for irritable bowel syndrome: a
controlled
trial. Digestion, 1991;50:36-42
23 Blanchard EB, Greene B, Scharff L, Schwarz-McMorris SP.
Relaxation training as a treatment for irritable bowel
syndrome.
Biofeedback Self Regul, 1993;18:125-132
24 Leahy A, Clayman C, Mason I, Lloyd G, Epstein O.
Computerised biofeedback games: a new method for teaching stress
management
and its use in irritable bowel syndrome. J R Coll Physician Lond,
1998;32:552-556
25 Cochrane S, Watson J, Watson B, Barrison I, Catnach S.
Which patients with irritable bowel syndrome benefit from
biofeedback
therapy? Gut, 1999;44(Suppl 1):A133
26 Chan J, Carr I, Mayberry JF. The role of acupuncture in the
treatment of irritable bowel syndrome: a pilot
study.
Hepatogastroenterology, 1997;44:1328-1330
| |
PubMed