Susan S. Krasner

Psychopathology in Irritable Bowel Syndrome: Support for a Psychophysiological Model

Previous research has established that patients with irritable bowel syndrome (IBS) frequently have comorbid psychiatric disorders. This study sought to establish if the timing of the onset of psychiatric disorders indicated that IBS was more likely to be caused by or more likely to cause psychological difficulties. Participants were 188 treatment-seeking IBS patients who were assessed for psychiatric diagnoses using a semistructured clinical interview. Timing of the onset of any lifetime psychiatric disorders was noted in an attempt to determine if psychiatric disorders were more likely to precede or follow the onset of IBS symptoms. Those participants that met criteria for an Axis I disorder sometime during their life were significantly more likely to develop an Axis I disorder before the onset of IBS symptoms. Anxiety disorders were the most likely disorder to develop before IBS. These results support the theory that psychiatric symptoms, especially anxiety, play a role in the development of IBS.

Self-Administered Cognitive Behavior Therapy for Moderate to Severe Irritable Bowel Syndrome: Clinical Efficacy, Tolerability, Feasibility

BACKGROUND & AIMS Given the limitations of conventional therapies and restrictions imposed on newer pharmacologic agents, there is an urgent need to develop efficacious and efficient treatments that teach patients behavioral self-management skills for relieving irritable bowel syndrome (IBS) symptoms and associated problems. METHODS Seventy-five Rome II diagnosed IBS patients (86% female) without comorbid gastrointestinal disease were recruited from local physicians and the community and randomized to either 2 versions of cognitive behavior therapy (CBT) (10-session, therapist-administered CBT vs 4-session, patient-administered CBT) or a wait list control (WLC) that controlled for threats to internal validity. Final assessment occurred 2 weeks after the 10-week treatment phase ended. Outcome measures included adequate relief from pain and bowel symptoms, global improvement of IBS symptoms (CGI-Improvement Scale), IBS symptom severity scale (IBS SSS), quality of life (IBSQOL), psychological distress (Brief Symptom Inventory), and patient satisfaction (Client Satisfaction Scale). RESULTS At week 12, both CBT versions were significantly (P < .05) superior to WLC in the percentage of participants reporting adequate relief (eg, minimal contact CBT, 72%; standard CBT, 60.9%; WLC, 7.4%) and improvement of symptoms. CBT-treated patients reported significantly improved quality of life and IBS symptom severity but not psychological distress relative to WLC patients (P < .0001). CONCLUSIONS Data from this pilot study lend preliminary empirical support to a brief patient-administered CBT regimen capable of providing short-term relief from IBS symptoms largely unresponsive to conventional therapies.

The role of stress in symptom exacerbation among IBS patients.

Over 200 treatment-seeking irritable bowel syndrome (IBS) patients completed 4 weeks of daily prospective measures of stress and gastrointestinal symptoms as well as retrospective measures of stress (life events over 12 months, hassles over 1 month). We also obtained the stress measures on 66 nonill controls. Irritable bowel syndrome patients report more frequent hassles than controls and a greater stress impact than controls. Using structural equation modeling, we found that the data were consistent with a model of robust autocorrelation effects of both week-to-week gastrointestinal (GI) symptom indices (r=.84) and stress indices (r=.73), as well as strong concurrent effects of stress on IBS symptoms (r=.90) and vice versa (r=.41). The data also were consistent with a model where there were effects of stress in Week t upon GI symptoms in Week t+1 and t+2, but they were mediated through the concurrent week effects and/or autocorrelation effects. There were no statistically significant independent pathways from stress in Week t to GI symptoms in Week t+1 or t+2. Thus, there is more support for a reciprocal relation between stress and symptoms than there is for a causal relation.

Type, rather than number, of mental and physical comorbidities increases the severity of symptoms in patients with irritable bowel syndrome.

BACKGROUND & AIMS Irritable bowel syndrome (IBS) has significant mental and physical comorbidities. However, little is known about the day-to-day burden these comorbidities place on quality of life (QOL), physical and mental function, distress, and symptoms of patients. METHODS We collected cross-sectional data from 175 patients with IBS, which was diagnosed on the basis of Rome III criteria (median age, 41 years; 78% women), who were referred to 2 specialty care clinics. Patients completed psychiatric interviews, a physical comorbidity checklist, the IBS Symptom Severity Scale, the IBS-QOL instrument, the Brief Symptom Inventory, the abdominal pain intensity scale, and the Short Form-12 Health Survey. RESULTS Patients with IBS reported an average of 5 comorbidities (1 mental, 4 physical). Subjects with more comorbidities reported worse QOL after adjusting for confounding variables. Multiple linear regression analyses indicated that comorbidity type was more consistently and strongly associated with illness burden indicators than disease counts. Of 10,296 possible physical-mental comorbidity pairs, 6 of the 10 most frequent dyads involved specific conditions (generalized anxiety, depression, back pain, agoraphobia, tension headache, and insomnia). These combinations were consistently associated with greater illness and symptom burdens (QOL, mental and physical function, distress, more severe symptoms of IBS, and pain). CONCLUSIONS Comorbidities are common among patients with IBS. They are associated with distress and reduced QOL. Specific comorbidities are associated with more severe symptoms of IBS.

Measuring health-related quality of life in patients with irritable bowel syndrome: can less be more?

Objective: This study assessed the ability of a brief, well-validated generic health-related quality of life (HRQOL) measure to characterize the symptom burden of patients with irritable bowel syndrome (IBS) with reference to a large survey of U.S. community-living adults. Methods: One hundred four Rome II diagnosed patients with IBS completed measures of pain, psychological dysfunction (neuroticism, somatization, distress, abuse), and HRQOL (SF-36, IBS-QOL, CDC HRQOL-4) during baseline assessment of a National Institutes of Health-funded clinical trial. The four-item CDC HRQOL-4 assesses global health and the number of days in the past 30 days resulting from poor physical health, poor mental health, and activity limitation. Results: Patients with IBS averaged 15 of 30 days with poor physical or mental health. These average overall unhealthy days exceeded those of respondents with arthritis, diabetes, heart disease/stroke, cancer, and class III obesity (body mass index ≥40 kg/m2) from the U.S. survey. Fifteen percent of patients identified musculoskeletal disorders, not IBS symptoms, as the major cause of their activity limitation. Overall unhealthy days among patients with IBS varied directly with IBS symptom severity, abuse, pain, and psychological distress. Controlling for personality variables that influence perception and reporting HRQOL did not diminish the statistical significance of associations between the CDC HRQOL-4 and other study measures. Conclusions: The CDC HRQOL-4 is a psychometrically sound, rapid, and efficient instrument whose HRQOL profile reflects the symptom burden of moderate-to-severe IBS, is sensitive to treatment effects associated with cognitive behavior therapy, and is not a proxy for personality variables identified as potential confounders of HRQOL. HRQOL is related to but not redundant with psychological distress. GERD = gastroesophageal reflux disease; HRQOL = health-related quality of life; IBS = irritable bowel syndrome; BRFSS = Behavioral Risk Factor Surveillance System; CDC = Centers for Disease Control and Prevention.

Rapid Response to Cognitive Behavior Therapy Predicts Treatment Outcome in Patients With Irritable Bowel Syndrome

BACKGROUND & AIMS Cognitive behavior therapy (CBT) is an empirically validated treatment for irritable bowel syndrome (IBS), yet it is unclear for whom and under what circumstances it is most effective. We investigated whether patients who achieved a positive response soon after CBT onset (by week 4), termed rapid responders (RRs), maintain treatment gains compared with non-rapid responders. We also characterized the psychosocial profile of RRs on clinically relevant variables (eg, health status, IBS symptom severity, distress). METHODS The study included 71 individuals (age, 18-70 y) whose IBS symptoms were consistent with Rome II criteria and were of at least moderate severity. Patients were assigned randomly to undergo a wait list control; 10 weekly 1-hour sessions of CBT; or four 1-hour CBT sessions over 10 weeks. RRs were classified as patients who reported adequate relief of pain, adequate relief of bowel symptoms, and a decrease in total IBS severity scores of 50 or greater by week 4. RESULTS Of patients undergoing CBT, 30% were RRs; 90% to 95% of the RRs maintained gains at the immediate and 3-month follow-up examinations. Although the RRs reported more severe IBS symptoms at baseline, they achieved more substantial, sustained IBS symptom reduction than non-rapid responders. Both dosages of CBT had comparable rates of RR. CONCLUSIONS A significant proportion of IBS patients treated with CBT have a positive response within 4 weeks of treatment; these patients are more likely to maintain treatment gains than patients without a rapid response. A rapid response is not contingent on the amount of face-to-face contact with a clinician.

The ties that bind: perceived social support, stress, and IBS in severely affected patients

Background  This study assessed the association between social support and the severity of irritable bowel syndrome (IBS) symptoms in a sample of severely affected IBS patients recruited to an NIH‐funded clinical trial. In addition, we examined if the effects of social support on IBS pain are mediated through the effects on stress.

The role of childhood abuse in Axis I and Axis II psychiatric disorders and medical disorders of unknown origin among irritable bowel syndrome patients

OBJECTIVE High rates of early abuse and psychopathology are commonly reported among treatment-seeking patients with irritable bowel syndrome (IBS). The purpose of this study is to further explore the relations among IBS, early abuse, Axes I and II psychopathology, and other medically unexplained disorders. METHODS One hundred and ninety-six IBS patients seeking nondrug treatment for their symptoms were characterized in terms of their gastrointestinal (GI) status, psychiatric status (Axis I and Axis II), early abuse status, and the presence of other functional disorders. Patients were divided into two groups based on early abuse status. RESULTS AND CONCLUSION No significant differences emerged between abused and nonabused groups on either the presence of Axis II disorders or other functional health conditions, although there were high levels of both in the IBS population. Patients with a history of abuse were significantly more likely to meet criteria for an Axis I disorder, especially substance abuse disorders, dysthymia, and generalized anxiety disorder.

Towards A Better Understanding of Anxiety in Irritable Bowel Syndrome: A Preliminary Look at Worry and Intolerance of Uncertainty

Although it has been fairly well established that symptoms of anxiety are often present in patients with irritable bowel syndrome (IBS), less is known about the role of worry and intolerance of uncertainty in this population. This study investigates the relations among these variables in a sample of treatment-seeking IBS patients. Although the results are preliminary, worry does seem to predict gastrointestinal symptom severity and, when combined with a measure of current anxiety, accounts for almost 30% of the variance. Intolerance of uncertainty differentiated diarrhea-predominant IBS patients from constipation-predominant IBS patients. Earlier research has taken a psychiatric perspective on anxiety in IBS patients—the current study may provide some support for shifting our focus to the cognitive biases that may be operating in IBS patients, regardless of the presence of an anxiety disorder. Implications for a cognitive therapy approach to IBS treatment are discussed.

Negative Aspects of Close Relationships are More Strongly Associated than Supportive Personal Relationships with Illness Burden of Irritable Bowel Syndrome

OBJECTIVE This study assessed the relative magnitude of associations between IBS outcomes and different aspects of social relationships (social support, negative interactions). METHOD Subjects included 235 Rome III diagnosed IBS patients (M age=41yrs, F=78%) without comorbid GI disease. Subjects completed a testing battery that included the Interpersonal Support Evaluation List (Social Support or SS), Negative Interaction (NI) Scale, IBS Symptom Severity Scale (IBS-SSS), IBS-QOL, BSI Depression, STAI Trait Anxiety, SOMS-7 (somatization), Perceived Stress Scale, and a medical comorbidity checklist. RESULTS After controlling for demographic variables, both SS and NI were significantly correlated with all of the clinical variables (SS rs=.20 to .36; NI rs=.17 to .53, respectively; ps<.05) save for IBS symptom severity (IBS-SSS). NI, but not SS, was positively correlated with IBS-SSS. After performing r-to-z transformations on the correlation coefficients and then comparing z-scores, the correlation between perceived stress, and NI was significantly stronger than with SS. There was no significant difference between the strength of correlations between NI and SS for depression, somatization, trait anxiety, and IBSQOL. A hierarchical linear regression identified both SS and NI as significant predictors of IBS-QOL. CONCLUSIONS Different aspects of social relationships - support and negative interactions - are associated with multiple aspects of IBS experience (e.g. stress, QOL impairment). Negative social relationships marked by conflict and adverse exchanges are more consistently and strongly related to IBS outcomes than social support.