Irritable Bowel Syndrome

Blanchard, E. B., Lackner, J. M., Gusmano, R., Gudleski, G. D., Sanders, K., Keefer, L., & Krasner, S. (2006). Prediction of treatment outcome among patients with irritable bowel syndrome treated with group cognitive therapy. Behaviour Research and Therapy, 44, 317-337.

Correspondence Address:
Edward B. Blanchard, Department of Psychology, Center for Stress and Anxiety Disorders, University of Albany-SUNY, 1400 Washington Avenue, Albany, NY, US, 12222-0001, ceblanchard@earthlink.net.

Abstract
Objective: Using a sample of over 125 patients with irritable bowel syndrome (IBS) who were treated with cognitive therapy administered in small groups, we sought to predict end of treatment and 3-month follow-up improvement in two changes indices of gastrointestinal (GI) symptoms (Pain/Discomfort Index which assessed change in abdominal pain, abdominal tenderness and bloating and Bowel Regularity Index which assessed change in diarrhea and constipation). We also sought to predict scores on IBS specific quality of life (QOL) and overall level of psychological distress using the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI). Significant, but modest, levels of prediction were found for prediction of improvement in GI symptoms (4-15% of variance). Stronger significant prediction was obtained for the QOL and global psychological distress measure with R2's ranging from 0.36 to 0.50. A wide variety of demographic, GI symptom, psychological status and psychiatric status variables entered the final prediction equations. (PsycINFO Database Record (c) 2006 APA, all rights reserved)

Blanchard, E. B., Lackner, J. M., Sanders, K., Krasner, S., Keefer, L., Payne, A., Gudleski, G. D., Katz, L., Rowell, D., Sykes, M., Kuhn, E., Gusmano, R., Carosella, A. M., Firth, R., & Dulgar-Tulloch, L. (2007). A controlled evaluation of group cognitive therapy in the treatment of irritable bowel syndrome. Behaviour Research and Therapy, 45, 633-648.

Correspondence Address:
Edward B. Blanchard, Center for Stress and Anxiety Disorders, University at Albany, Albany, NY, USA, 12222, ebblanchard@yahoo.com.

Abstract
We randomized, at two sites, 210 patients with Rome II diagnosed irritable bowels syndrome (IBS), of at least moderate severity, to one of three conditions: group-based cognitive therapy (CT; n = 120), psychoeducational support groups (n = 46) as an active control, or intensive symptom and daily stress monitoring (n = 44). One hundred eighty-eight participants completed the initial treatment. Those in symptom monitoring were then crossed over to CT. For an intent to treat analysis on a composite GI symptom measure derived from daily symptom diaries, both CT and the psychoeducational support groups were significantly more improved than those in the intensive symptom monitoring condition, but the CT and psychoeducational support group did not differ. Among treatment completers on the same composite measure of GI symptoms, again, both CT and psychoeducational support groups were statistically superior to symptom monitoring but did not differ on the symptom composite, or on any other measure. On individual IBS symptoms, both CT and psychoeducational support were statistically superior to symptom monitoring on reductions in abdominal pain and tenderness and for flatulence. Patient global ratings at the end of treatment showed the two active conditions statistically superior to symptom monitoring on change in Bowel Regularity, with CT superior to symptom monitoring on reduction in overall pain and in improvement in sense of well-being. Three-month follow-up data on 175 patients revealed maintenance of significant improvement or continued significant improvement on all IBS symptoms, including the McGill Pain Questionnaire. Group CT and psychoeducational support groups continued not to differ on any measure. We thus conclude that group CT is not superior to an attention placebo control condition. (PsycINFO Database Record (c) 2007 APA, all rights reserved)

Kennedy, T., Jones, R., Darnley, S., Seed, P., Wessely, S., & Chalder, T. (2005). Cognitive behaviour therapy in addition to antispasmodic treatment for irritable bowel syndrome in primary care: Randomised controlled trial. British Medical Journal, 331, 435.

Correspondence Address:
Roger Jones: Department of General Practice and Primary Care, Guy's, King's and St Thomas' School of Medicine, King's College, London, United Kingdom, SE11 6SP, R.Jones_roger.jones@kcl.ac.uk.

Abstract
Objective: To assess the efficacy of cognitive behaviour therapy delivered in primary care for treating irritable bowel syndrome. Design: Randomised controlled trial. Setting: 10 general practices in London. Participants: 149 patients with moderate or severe irritable bowel syndrome resistant to the antispasmodic mebeverine. Interventions: Cognitive behaviour therapy delivered by trained primary care nurses plus 270 mg mebeverine taken thrice daily compared with mebeverine treatment alone. Main Outcome Measures: Primary measures were patients' scores on the irritable bowel syndrome symptom severity scale. Secondary measures were scores on the work and social adjustment scale and the hospital anxiety and depression scale. Results: Of 334 referred patients, 72 were randomised to mebeverine plus cognitive behaviour therapy and 77 to mebeverine alone. Cognitive behaviour therapy had considerable initial benefit on symptom severity compared with mebeverine alone, with a mean reduction in score of 68 points (95% confidence interval 103 to 33), with the benefit persisting at three months and six months after therapy (mean reductions 71 points (109 to 32) and 11 points (20 to 3)) but not later. Cognitive behaviour therapy also showed significant benefit on the work and social adjustment scale that was still present 12 months after therapy (mean reduction 2.8 points (5.2 to 0.4)), but had an inconsistent effect on the hospital anxiety and depression scale. Conclusion: Cognitive behaviour therapy delivered by primary care nurses offered additional benefit over mebeverine alone up to six months, although the effect had waned by 12 months. Such therapy may be useful for certain patients with irritable bowel syndrome in primary care. (PsycINFO Database Record (c) 2006 APA, all rights reserved)

Lackner, J. M., Coad, M. L., Mertz, H. R., Wack, D. S., Katz, L. A., Krasner, S. S., Firth, R., Mahl, T. C., & Lockwood, A. H. (2006). Cognitive therapy for irritable bowel syndrome is associated with reduced limbic activity, GI symptoms, and anxiety. Behaviour Research and Therapy, 44, 621-638.

Correspondence Address:
Jeffrey M. Lackner, Department of Medicine, Division of Gastroenterology, Behavioral Medicine Clinic, University at Buffalo School of Medicine, SUNY, ECMC, 462 Grider Street, Buffalo, NY, US, 14215, lackner@buffalo.edu.

Abstract
This study sought to identify brain regions that underlie symptom changes in severely affected IBS patients undergoing cognitive therapy (CT). Five healthy controls and 6 Rome II diagnosed IBS patients underwent psychological testing followed by rectal balloon distention while brain neural activity was measured with O-15 water positron emission tomography (PET) before and after a brief regimen of CT. Pre-treatment resting state scans, without distention, were compared to post-treatment scans using statistical parametric mapping (SPM). Neural activity in the parahippocampal gyrus and inferior portion of the right cortex cingulate were reduced in the post-treatment scan, compared to pre-treatment (x, y, z coordinates in MNI standard space were -30, -12, -30, P = 0.017; 6, 34, -8, P = 0.023, respectively). Blood flow values at these two sites in the controls were intermediate between those in the pre- and posttreatment IBS patients. Limbic activity changes were accompanied by significant improvements in GI symptoms (e.g., pain, bowel dysfunction) and psychological functioning (e.g., anxiety, worry). The left pons (-2, -26, -28, P = 0.04) showed decreased neural activity which was correlated with post-treatment anxiety scores. Changes in neural activity of cortical-limbic regions that subserve hypervigilance and emotion regulation may represent biologically oriented change mechanisms that mediate symptom improvement of CT for IBS. (PsycINFO Database Record (c) 2006 APA, all rights reserved)