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Mind-Body Digestive Center:
Journal Reviews
Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD)- Psychosocial Risk Markers for New Onset Irritable Bowel Syndrome: Results of a Large Prospective Population-based Study
- Long-term Improvement in Functional Dyspepsia Using Hypnotherapy
- Long Term Benefits of Hypnotherapy for Iritable Bowel Syndrome
Literature reviews: Irritable Bowel Syndrome in Inflammatory Bowel Disease
This is an important addition to our research article reviews. Patients with the inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis, have symptoms that are similar to irritable bowel syndrome (IBS). After IBD is treated successfully, examination of the colon may show that there is no longer any sign of active inflammation. However, IBD patients may continue to suffer from gastrointestinal symptoms that fit the diagnosis of irritable bowel syndrome (IBS). The articles that we review look at the relationship between IBD and IBS, particularly whether IBS may afflict IBD patients. Studying patients whose IBD is in remission allows us to understand the important role of IBS in their lives.
1. Coping strategies and interpersonal support in patients with irritable bowel syndrome and inflammatory bowel disease.
Jones MP, Wessinger S, Crowell MD. Clinical Gastroenterology and Hepatology 4: 474-481, 2006.BACKGROUND:
The goal of this study was to examine the psycho-social issues of quality of life, interpersonal support and coping strategies, in patients with irritable bowel syndrome (IBS, and inflammatory bowel disease (IBD).
METHODS:
74 patients with IBS, 48 patients with IBD and 55 controls were compared. Questionnaires included a quality of life measure, designed for IBS and IBD respectively; a psychiatric symptom checklist which included a number of psychological symptoms such as anxiety and depression; a ways of coping questionnaire (coping can be defined as finding ways to best deal with the stress of chronic illness like IBS and IBD); and an interpersonal support measure.
RESULTS AND CONCLUSIONS:
While IBS is considered a "functional" disorder and IBD is an "organic" disease, both conditions had equally significant reduced quality of life, compared to controls. The same result was found for psychiatric distress. Interpersonal support was also decreased in both IBS and IBD patients. At the MBDC, we published a research article showing that IBS patients with worse symptoms had less interpersonal support.
Interestingly, patients and healthy controls had similar overall coping scores. There were some specific differences: the highest coping score in IBS was planful problem solving, and both groups scored high in seeking social support. IBD patients were found to use avoidance as a coping strategy.
CONCLUSIONS:
For IBS patients, the important finding in this report is that they have similar quality of life and psychosocial issues as patients with active inflammatory bowel disease. This is consistent with the idea that IBS can be as debilitating as IBD and deserves comparable attention from physicians and psychologists. The results also showed that both conditions lack sufficient social support from intimate others though the coping questionnaire shows that they desire more support. Interpersonal support is a key focus at the MBDC.
2. Quality of life in inflammatory bowel disease in remission: the impact of IBS-like symptoms and associated psychological factors.
Simren M, Axelsson J Gillberg R, Abrahamsson H, Svedlund J, Bjornsson ES. The American Journal of Gastroenterology 97: 389-396, 2002.BACKGROUND:
The purpose of the study was to determine whether IBD patients in remission (meaning they had no evidence of active inflammation) may suffer from IBS even though their colons are not inflamed.
METHODS:
43 patients with ulcerative colitis (UC) and 40 patients with Crohn's disease (CD), all in remission, were studied. They completed four questionnaires: a gastrointestinal rating scale, an anxiety and depression scale, another anxiety scale related to acute stressful situations, and a psychological general well-being index. IBS was diagnosed by the usual symptoms of abdominal pain or bloating accompanied by diarrhea or constipation.
RESULTS:
14 of 43 (33%) UC patients had IBS and 23 of 40 (57%) of CD patients had IBS. These percentages are two to three times higher than expected, compared to usual population surveys. Not only can patients with IBD have IBS as well, but this occurs quite commonly.
The authors also compared the IBD patients in remission who had IBS to the IBD patients in remission who did not have IBS. Quality of life was worse in the IBS/IBD group, especially in Crohn's disease. Anxiety and depression were also more common if IBS was present, again more common in Crohn's patients than ulcerative colitis.
3. Ulcerative colitis and irritable bowel syndrome: relationships with quality of life.
Ansari R, Attari F, Razjouyan H, Etemade A, Amjadi H, Merat S, Malekzadeh R. European Journal of Gastroenterology & Hepatology. 20: 46-50, 2008.BACKGROUND:
This article is similar to the previous one but IBD patients only had ulcerative colitis, not Crohn's disease. It records the percent of patients with ulcerative colitis (UC), in remission (no active inflammation on colonoscopy), who have irritable bowel syndrome. In addition, it compares quality of life in four groups, ulcerative colitis in remission with IBS, ulcerative colitis in remission without IBS, active ulcerative colitis and a control group.
METHODS:
95 patients with ulcerative colitis were studied. 50 patients were in remission and 45 patients had active disease. IBS was diagnosed in patients with no sign of active colitis, according to Rome II symptom criteria. Quality of life was evaluated by the SF-36 questionnaire which assesses a person's physical and emotional well being.
RESULTS:
50 UC patients were in remission. 23 (46%) of the 50 had symptoms that fit the diagnosis of IBS. This confirms the previous paper's findings that IBS occurs very frequently in patients with IBD.
Quality of life measures, including both physical and emotional aspects of living, separated the subjects into two groups. Patients with UC in remission with IBS, and patients with active UC, had worse quality of life than UC in remission or controls.
This indicates that patients with UC in remission who have IBS, suffer the same physical and psychological quality of life consequences as patients with active ulcerative colitis.
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Psychosocial Risk Markers for New Onset Irritable Bowel Syndrome: Results of a Large Prospective Population-based Study
Nicholl BJ, Halder SL, Macfarlane DG, Thompson S, O'Brien M, Mulesh M, McBeth J. Pain. 2008; in press.BACKGROUND:
Previous studies have examined the relationship of psychosocial factors and IBS and found that individuals who have IBS also have an increased level of depression, anxiety and other psychological symptoms. However, it is unknown if these psychosocial factors act as risk markers for the onset of IBS as they also could be understood as consequences of having the illness.
STUDY DESIGN:
A postal survey was conducted to ascertain participants' psychosocial status and severity of abdominal pain. Participants were between the ages of 25 and 65 and were randomly selected from three general practitioners' offices in north-west England. The study focused on individuals who did not have IBS at the time of the initial questionnaires. Diagnosis of IBS was based on Rome symptom criteria.
RESULTS:
86 subjects (3.5%) who were free of IBS at the outset were found to develop IBS over the 15 month time course of the study. The onset of IBS was higher in women (4.6%) than men (2.1%).
Patients with scores indicating psychological distress and excess concern about their health were more likely to develop IBS. Higher scores in Illness Behavior Scale (related to number of doctor visits and worry about illness), Estimation of Sleep Problems, HAD Anxiety and Depression scale (records feelings of anxiety or depression over the previous week), Somatic Symptom Checklist (a measure of symptoms other than IBS), Health Anxiety (worry about getting a serious illness) and Threatening Life Events (stressful experience over the previous six months) scales were all related to the prevalence of IBS at follow-up. The highest correlation was with the Illness Behavior Scale where individuals with scores in the highest third were seven times more likely to develop IBS.
Also, the more abnormal questionnaire scores, the higher probability of developing IBS. Of the 86 subjects who developed IBS, 80.2% had at least two abnormal questionnaire scores. High levels of illness behavior, anxiety, sleep problems and other somatic symptoms were all independent predictors for IBS.
COMMENTS:
This report demonstrates that people with certain psychological characteristics are more prone to develop IBS than others. While this does not mean that IBS is caused by psychological problems, it supports the idea that IBS is a mind-body illness wherein patients have a psychological substrate that contributes to the expression of symptoms. This underlines our belief that treatment, especially of patients with ongoing illness, requires a holistic mind-body approach.
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Long-term Improvement in Functional Dyspepsia Using Hypnotherapy
E.L. Calvert, L.A. Houghton, P. Cooper, J. Morris and P.J. Whorwell Gastroenterology 2002; 123: 1778-1785BACKGROUND:
Hypnotherapy has been shown to be effective in the treatment of irritable bowel syndrome (IBS) and in the improvement of symptoms and quality of life. This study intends to determine if hypnotherapy can be as effective in the treatment of functional dyspepsia (FD) as it is in IBS and its effectiveness will be compared to the use of supportive therapy with medication as well as medical treatment.
MATERIALS AND METHODS:
A total of 126 patients were divided into one of three groups: hypnotherapy (32 patients), supportive therapy plus placebo medication (48 patients) or medical treatment with medication (46 patients). They received treatment for 16 weeks and subsequently underwent a follow-up after 40 weeks. During the treatment phase, patients received 12, 30 minute sessions for individuals in the hypnotherapy and supportive therapy group, while individuals in the medical group only received four visits in which medication was disbursed. Patients' symptoms, quality of life, anxiety, depression and the economic impact of functional dyspepsia were assessed.
RESULTS:
After the completion of treatment, a significant improvement was found in the hypnotherapy group compared to the other two groups. At the end of the treatment phase, the median symptom improvement for patients in the hypnotherapy group was 59%, whereas it was 40.7% for the supportive therapy plus placebo group and 33% for the medical treatment group. A difference was also seen in individual scores that supports hypnotherapy's effectiveness.
At the follow-up phase, hypnotherapy patients' symptoms improved (73%) a great deal more than the other two groups: supportive (34%) and medical (43%). All symptoms, except for nausea, improved in the hypnotherapy group, whereas improvement was not maintained in the other groups.
With regards to quality of life, patients in the hypnotherapy groups significantly improved (42%) at the end of the treatment phase as compared to the other two groups: medical (11%) and supportive (10%). At the follow-up phase, quality of life for patients in the hypnotherapy group improved (44%) in comparison to the medical group (20%), however, the supportive group exhibited a gradually increasing quality of life (43%). Anxiety was reduced in both hypnotherapy (from 8.5 to 5) and supportive (from 10 to 6.5) groups during treatment. However, no differences were significant when all 3 groups were examined.
It is important to note that 82% of patients from the supportive group and 90% of patients from the medical group ended up using some form of medication, where 0% of patients from the hypnotherapy group did. Also, the total number of medical consultations was significantly lower after hypnotherapy as opposed to supportive group therapy and medical treatment.
DISCUSSION:
This study indicates that for both the short and long-term, hypnotherapy is more successful than supportive therapy plus medication as well as medical treatment in managing the symptoms of functional dyspepsia as well as the patients' quality of life. In addition, there are economic advantages to the use of hypnotherapy as the need for medication is non-existent. Therefore, money does not need to be expended on medication over a long period of time to help manage symptoms.
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Long Term Benefits of Hypnotherapy for
Irritable Bowel Syndrome
W M Gonsalkorale, V Miller, A Afzal, P J WhorwellGut 2003:52:1623-1629
Gut directed hypnotherapy is now being used to treat Irritable Bowel Syndrome. There is strong evidence from a number of research reports that hypnotherapy can relieve the symptoms of irritable bowel syndrome in the short term. However, there is no long-term data on its benefits and this information is essential before the technique can be widely recommended. This study aimed to answer this question.
In this article, gut directed hypnotherapy comprised up to 12 weekly 1 hr sessions. Each session consists of induction of the hypnotic state and deepening procedures, followed by "ego strengthening" suggestions relevant to the individual. These are accompanied by further suggestions and interventions, such as inducing warmth in the abdomen using the hands and imagery directed towards controlling normal gut function.
A set of 3 questionnaires was mailed to 273 patients with IBS, who had received gut directed hypnotherapy at least one year previously. The questionnaires focused on rating the patients IBS symptoms, as well as their quality of life, anxiety, and depression.
RESULTS:
Directly after completion of hypnotherapy, 147 patients (86.8%) claimed their symptoms improved, while 27 (13.2%) reported no change in symptoms. No patients reported worsening symptoms. In response to the questionnaires administered over one year later, 81.3 % of those who had improvement in the symptoms maintained their improvement, with a majority stating their symptoms had improved even further.
Patients were followed for up to five years after termination of treatment and there was no significant decrease in symptom improvement. Of all the patients, 93.1% considered the course of hypnotherapy had been worthwhile.
Before hypnotherapy, all patients showed similar quality of life measures. Directly after therapy, those who reported an improvement in IBS symptoms also noted an improvement in quality of life. In the follow up study, those whose symptom improvement was sustained still had an improved quality of life.
Scores for anxiety and depression were similar across all patients before hypnotherapy treatment. Anxiety and depression improved in all patients, but overall improvement was greater in the groups that reported improvement in their IBS symptoms.
It is important to note that the continued improvement seen by patients in this study cannot be explained by the use of other treatments after finishing hypnotherapy. Only 14 (9.7%) of those who reported improved symptoms tried other treatments, (including dietary changes, alternative medicines, yoga, and reflexology) and found these helpful.
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