Pain perception in irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by chronic abdominal discomfort or pain in the absence of detectable organic disease. IBS is common and is associated with a significant impairment in health-related quality of life. Enhanced perception of visceral stimuli ("visceral hypersensitivity") appears to be an important pathophysiological mechanism. Early IBS studies using functional brain imaging techniques suggest an alteration in central pain modulation circuits, rather than an increased sensitivity of peripheral visceral pain pathways. The frequent comorbidity with psychiatric disorders suggests the possibility of shared pathophysiological mechanisms and etiologic factors.     

The role of coping, anxiety, and stress in depression post-acute coronary syndrome

Depressive symptoms are common and can affect prognosis following acute coronary syndromes (ACS). This study examined the psychological factors, coping, anxiety, and perceived stress associated with depression following ACS. Psychological variables were assessed in 15 females and 66 males (M = 57 years, SD = 12). Repeated measures at 2, 12, and 24 weeks post-ACS compared depression, anxiety, perceived stress, and coping resources as determined by the Cardiac Depression Scale, Beck Depression Inventory-II, State Trait Anxiety Inventory, Perceived Stress Scale, and Coping Resources Inventory. Depression, anxiety, and perceived stress remained high in the depressed group across time. Coping scores at 2 weeks post-ACS predicted depression scores at 24 weeks post-ACS. It appears that trait anxiety and coping resources are related to depressive symptoms post-ACS.     

Cognitive-behavioral treatment of irritable bowel syndrome

There is increasing evidence that supports the view that irritable bowel disorder (IBS) is a disorder of brain-gut function. Cognitive-behavioral therapy (CBT) has received increased attention in light of this recent shift in the conceptualization of IBS. This review has two main aims. The first is to provide a critical review of controlled trials on CBT for IBS. The second is to discuss ways of further developing CBT interventions that are more clinically relevant and meaningful to health care providers and individuals with a diagnosis of IBS. A theme from a CBT intervention will be presented to illustrate how CBT interventions can be incorporated within a larger social context. A review of CBT for IBS lends some limited support for improvement in some IBS symptoms and associated psychosocial distress. This conclusion needs to be expressed with some caution, however, in light of many methodological shortcomings including small sample sizes, inadequate control conditions and failure to identify primary versus secondary outcome measures. In addition, future studies will need to further develop more relevant CBT protocols that more fully integrate the patient's perspective and challenge social cognitions about this stigmatized disorder.     

Early abuse, psychiatric diagnoses and irritable bowel syndrome

In a population of 71 (57 female, 14 male) IBS patients seeking psychological treatment, we found expected levels of childhood sexual and physical abuse (57.7%) and expected levels of current Axis I psychiatric disorders (54.9%). Moreover, we found those who had been victims of early abuse had higher current Beck Depression Inventory scores. However, contrary to expectations, there were no significant associations between early abuse and current psychiatric disorder in this population, suggesting that those individuals with psychological distress are not exactly the same group with a history of abuse.     

The relationship between beliefs about emotions and quality of life in irritable bowel syndrome

Suppression of undesirable emotions, as well as beliefs about the unacceptability of experiencing and expressing emotions, have both been shown to be related to poorer health-related outcomes in several clinical groups. Potential models through which these variables relate have yet to be tested in those with irritable bowel syndrome (IBS) and are therefore examined in the current article. Online questionnaires were administered to people with IBS (n = 84) to test a mediation model in which beliefs about the unacceptability of emotions are associated with greater emotional suppression, which in turn relates to increased affective distress and consequently poorer quality of life. An alternate model to test the direction of effect along with two further models using support-seeking as mediators of the same predictor and outcome were also tested. Emotional suppression and affective distress (in that particular order) mediate the relationship between beliefs about emotions and quality of life IBS. The models using support-seeking as mediators of the relationship between beliefs about emotions and the two outcomes were not supported. These findings suggest a role for emotional processing in medically unexplained symptoms and imply the need to address such beliefs about emotions in psychological therapies.     

Cognitive therapy for irritable bowel syndrome is associated with reduced limbic activity, GI symptoms, and anxiety

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 post-treatment 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.     

Brief cognitive-behavioral internet therapy for irritable bowel syndrome

While cognitive-behavioral therapy for IBS is quite effective, the limited availability of competent therapists and lack of access to treatment remain problematic. This paper reports on a small, randomized, controlled trial of a five week internet based cognitive-behavioral intervention for IBS with limited therapist feedback via e-mail. Fifty-four IBS patients were recruited via the internet and randomly assigned to either immediate treatment or a wait-list control group. Thirty-one subjects completed the post-treatment assessment. 77% of treatment completers also completed a 3-month follow-up assessment. Treatment completers experienced statistically and clinically significant declines in IBS symptoms and improvements in quality of life. Those gains were substantially maintained at follow-up. Treatment efficacy was partially mediated by reductions in the tendency to catastrophize the social and occupational implications of symptoms, suggesting that catastrophizing may be an important target for treatment.     

The role of defeat and entrapment in depression, anxiety, and suicide

Defeat and entrapment are psychological constructs that have played a central role in evolutionary accounts of depression. These concepts have since been implicated in theoretical accounts of anxiety disorders and suicidality. The current article reports on a systematic review of the existing research investigating the links among defeat, entrapment, and psychopathology in the domains of depression, suicidality, posttraumatic stress disorder (PTSD), and other anxiety syndromes. Fifty-one original research articles were identified and critically reviewed. There was strong convergent evidence for a link with depressive symptoms, across a variety of clinical and nonclinical samples. Preliminary support for an association with suicidality was also observed, with effects not readily explainable in terms of comorbid depression. There was strong evidence for an association between defeat and PTSD, although this may have been partly accounted for by comorbid depression. The findings for other anxiety disorders were less consistent. There was, however, evidence that social anxiety in individuals with psychosis may be related to perceptions of entrapment. Overall, there was evidence that perceptions of defeat and entrapment were closely associated with various forms of human psychopathology. These effects were often in the moderate to large range and superseded the impact of other environmental and psychological stressors on psychopathology. We provide a unified theoretical model of how defeat and entrapment may contribute to these different psychopathological conditions. Clinical implications and avenues for future research are discussed.     

Prediction of outcome from cognitive-behavioral treatment of irritable bowel syndrome

The presence of a diagnosable Axis I psychiatric disorder predicted significantly (P < 0.001) lower likelihood of significant improvement among 90 irritable bowel syndrome patients given cognitive and behavioral treatments to help the disorder. Other psychological tests, including the MMPI, BDI, STAI, as well as demographic variables, failed to yield significant prediction.     

Gender differences in depression: The role of anxiety and generalized negative affect

This study used the tripartite model of depression and anxiety to examine whether gender differences in depression may be accounted for, in part, by the overlap of depression with anxiety and negative affectivity. The tripartite model distinguishes between pure forms of depression and anxiety, co-morbid depression and anxiety, and mixed anxiety-depression. One hundred-six college students completed questionnaires that measured depression, anxiety, and negative and positive affectivity. Results were moderately consistent with hypotheses. Specifically, the proportion of women versus men was significantly higher in the categories of co-morbid depression and anxiety and mixed anxiety-depression, but not in the categories of specific (i.e., pure) depression or anxiety. It is argued that specific depression may be equally prevalent in men and women, but that other depression-related syndromes may be more common among women than men.     

Behaviorally treated irritable bowel syndrome patients: a four-year follow-up

Nineteen of 27 patients suffering from Irritable Bowel Syndrome (IBS) who had completed a multicomponent treatment involving progressive muscle relaxation, thermal biofeedback, cognitive therapy and IBS education were located and evaluated 4 yr posttreatment. Seventeen of 19 (89.5, or 63% of the total original sample) rated themselves as more than 50% improved. Six of the 12 patients (50%) who submitted symptom monitoring diaries met our criteria for clinical improvement, i.e. achieving at least a 50% reduction in primary IBS symptom scores. The means on all measures at long-term follow-up were lower than those obtained prior to treatment. When follow-up symptom means were compared with pretreatment means, significant (P less than 0.05) reductions were obtained on abdominal pain/tenderness, diarrhea, nausea, and flatulence.     

A controlled evaluation of group cognitive therapy in the treatment of irritable bowel syndrome

We randomized, at two sites, 210 patients with Rome II diagnosed irritable bowel 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.     

Visceral sensitivity as a mediator of outcome in the treatment of irritable bowel syndrome

Patients with irritable bowel syndrome (IBS) experience anxiety about visceral sensations, leading to avoidance behaviors and hypervigilance that maintain IBS symptoms. The current study used data from a clinical trial that compared a treatment aimed at reducing anxiety about visceral sensations (interoceptive exposure; IE) to an attention control (AC) and a CBT-based stress-management treatment (SM) to examine whether changes in visceral sensitivity mediated IBS symptom and quality of life outcomes. Data from participants who completed one of the three treatments (N = 76) were subjected to mediation analyses. Visceral sensitivity mediated treatment outcomes across all outcome measures and across all treatment groups, with no differences between IE and the other treatment groups. This finding suggests that psychosocial treatments for IBS may work by decreasing visceral sensitivity, and the degree to which visceral sensitivity is decreased is related to outcome, suggesting IE may be the preferable treatment option.     

Interpersonal communication apprehension,topic avoidance,and the experience of irritable bowel syndrome

Through the lens of the theory of inhibition and confrontation ( Pennebaker, 1989 ), this study explored the relationships that interpersonal communication apprehension and topic avoidance in one's closest relationship share with the experience of irritable bowel syndrome (IBS). Specifically, an online survey that studied U.S. IBS‐diagnosed and non‐IBS subsamples examined person–partner communication apprehension, amount of overall topic avoidance, and reasons for topic avoidance in relation to four IBS experience variables. Communication apprehension displayed a particularly strong relationship with multiple aspects of the IBS experience, and a number of the communication avoidance variables varied according to IBS diagnosis. Implications for the theoretical understanding of interpersonal communication processes in the specific context of IBS and general chronic health conditions are discussed.     

Physiological reactivity to stressors in irritable bowel syndrome patients, inflammatory bowel disease patients and non-patient controls.

Irritable Bowel Syndrome (IBS) patients were compared with Inflammatory Bowel Disease (IBD) patients and non-patient controls on four separate physiological measures (heart rate, finger-tip temperature, skin resistance level, and forehead EMG) for their physical reactivity to 'laboratory stressors'. It was predicted that the IBS patients would respond to these stressors with more physiological reactivity than the two other groups. There were initial basal differences among the groups on heart rate and finger-tip temperature: in general, the IBS patients had lower basal heart rates and the non-patient controls had lower finger-tip temperatures. These findings are contrary to the previous body of literature regarding possible sympathetic nervous system (SNS) arousal states in the IBS patient. The results also indicated IBS patients were not significantly different than the IBD patients or the non-patient controls in their reactivity to stressors. Previous literature has suggested that IBS in their reactivity to stressors. Previous literature has suggested that IBS patients have an enhanced SNS arousal or an SNS mediated reactivity to environmental stressors, our current study has not found these results.     

Long-term follow-up of internet-delivered exposure and mindfulness based treatment for irritable bowel syndrome

We conducted a follow-up of a previously reported study of internet-delivered cognitive behavior therapy (CBT) for IBS, based on exposure and mindfulness exercises (Ljótsson et al. (2010). Internet-delivered exposure and mindfulness based therapy for irritable bowel syndrome – a randomized controlled trial. Behaviour Research and Therapy, 48, 531–539). Seventy-five participants from the original sample of 85 (88%) reported follow-up data at 15–18 months (mean 16.4 months) after completing treatment. The follow-up sample included participants from both the original study’s treatment group and waiting list after it had been crossed over to treatment. Intention-to-treat analysis showed that treatment gains were maintained on all outcome measures, including IBS symptoms, quality of life, and anxiety related to gastrointestinal symptoms, with mainly large effect sizes (within-group Cohen’s d = 0.78–1.11). A total of fifty participants (59% of the total original sample; 52% of the original treatment group participants and 65% of the original waiting list participants) reported adequate relief of symptoms. Improvements at follow-up were more pronounced for the participants that had completed the full treatment and maintenance of improvement did not seem to be dependent on further treatment seeking. This study suggests that internet-delivered CBT based on exposure and mindfulness has long-term beneficial effects for IBS-patients.