Many medical conditions are simple in nature. They can be handled with a single kind of treatment, and the symptoms go away. A good example is the common and annoying condition called athlete’s foot. This is a simple fungal infection, often picked up in locker rooms or gyms. Once symptoms develop (itching and burning in the areas between the toes) and the characteristic red, flaky rash is seen, the diagnosis is made (usually by the patient) and treatment is started. A topical antifungal agent, purchased without a prescription, is applied to the affected area once or twice a day, and within days to weeks the infection is cleared up. The infection is limited to the skin; other organ systems are not involved and additional therapies need not be employed.
Irritable bowel syndrome is entirely different from that scenario. As we have learned, irritable bowel syndrome affects multiple parts of the GI tract, often all at the same time. Multiple types of symptoms occur and can differ dramatically from one person to the next. The symptoms can be accompanied by significant psychological effects that can in turn dramatically affect the course of the disease. IBS is frequently underdiag-nosed (symptoms are ignored by the health care provider or attributed to another disease process); in addition, it is often misdiagnosed and thus treated inappropriately. Even when the condition is correctly diagnosed, the symptoms can be difficult to control in some people.
We all wish that a single therapy could be used to treat all of the symptoms of IBS and that all patients could be cured, but we are painfully aware that this is not the case, at least not yet. Although several available medications can significantly improve some of the symptoms of IBS, they are not effective in all patients, nor are they effective to the same degree in all of those who do respond to them. For that reason, researchers, clinicians, and patients have looked to alternative and complementary therapies for help in the treatment of IBS. Some of these therapies are reviewed in Chapter 21. This chapter will focus on therapies to improve the mental and physical health of individuals who have IBS. Maggie’s case illustrates some of these treatment options.
Maggie, who is now a 24-year-old law student, started having problems with abdominal discomfort, bloating, diarrhea, and urgency as a high school student. Sometimes her symptoms were so severe she could barely finish a meal before having to run to the bathroom with diarrhea. Separate one-month trials of a wheat-free diet and then a lactose-free diet did not improve her symptoms. She saw her family doctor, who reviewed her history (nothing worrisome came to light), performed a thorough physical examination (which was normal), performed some simple blood tests (all of which turned out normal) and then made the diagnosis of IBS. He recommended a regimen of small, frequent meals in conjunction with as-needed doses of an antidiarrheal medicine (Imodium) and a smooth-muscle antispasmodic (dicyclomine). Maggie’s symptoms improved dramatically during the next several years.
In college, however, Maggie’s symptoms worsened. She noticed that they flared before an exam or before a major paper was due. On a bad day, she might have 10 loose, watery bowel movements with significant abdominal cramping and urgency. These episodes left her feeling drained and wiped out. Maggie went to the college health clinic and was referred to the university health center, where she saw a gastroenterolo-gist. As it had been several years since any blood work had been done, Dr. Marzetta ordered a complete blood count, thyroid tests, a sedimentation rate (ESR), and an antibody test for celiac disease. Fortunately, all of the test results were completely normal. Dr. Marzetta also ordered some simple stool cultures (fecal leukocytes and ova and parasites) and scheduled a colonoscopy, to make sure that Maggie did not have inflammatory bowel disease. The stool studies all yielded normal results, and the colonoscopy, including biopsies at intervals throughout the colon, showed no abnormalities. This reassured Maggie, and she and Dr. Marzetta decided to use a combination of a different antidiarrheal agent, Lomotil, and sublingual hyoscyamine to treat the abdominal discomfort. They also discussed the fact that Maggie’s symptoms seemed to get worse during times of stress. Maggie admitted that she got anxious at times; in fact, her brothers and sisters had nicknamed her “Nervous Nellie” and her parents said that she had always had a “sensitive stomach.”
Maggie tried these new medications for a while, but she continued to experience symptoms. By this time, Maggie was starting to become a little depressed; she worried that she would suffer from these symptoms all of her life. Back at college, she saw a counselor. They decided to try treating the mild anxiety and depressive symptoms with a low dose of sertraline (Zoloft). This medication made Maggie a little groggy, so paroxetine (Paxil) was tried next, which dramatically improved Maggie’s mood. Over the next year, the combination of small and frequent meals, Paxil, Lomotil, and hyoscyamine worked well for Maggie, and she graduated with honors.
After moving to a new city and starting law school, however, all of her symptoms worsened again. She tried increasing the doses of Lomotil and hyoscyamine, but the higher doses made her feel sleepy and gave her a dry mouth. She saw a local gastroenterologist, who started her on amitriptyline (Elavil), one of the tricyclic antidepressants that often eases diarrhea; however, even a very low dose made her feel groggy the next day, and she had to stop taking the medication.
Maggie came in to see me during her winter break. She accurately reported her history, including that several of the medicines she had used had improved her IBS symptoms but caused side effects that made it difficult for her to function. She also admitted that her symptoms worsened during stressful situations. Maggie was beginning to realize that, for her, IBS was likely to be a longstanding problem. She stated that her goals were to minimize her symptoms, improve her overall health and sense of well-being, and minimize medication use. We talked about a wide range of therapies and the risks and benefits of each. Maggie decided that she would focus on a regimen of routine exercise (something new for her), diet (low-fat, low-fiber, no caffeine, small frequent meals), and cognitive behavioral therapy, in addition to continuing a low dose of Paxil and using Imodium as needed.
Over the next several months, Maggie attended weekly and then every other week counseling sessions, and she noted a significant improvement in her symptoms. Her mood lightened, she felt more confident, and when she did have GI symptoms she was less anxious that they would escalate out of control. She took Imodium before a major examination or a mock trial, and it kept her symptoms manageable. Her abdominal discomfort was nearly gone. Even though she had an occasional flare of her IBS, the episodes were much less severe than in the past and, significantly, were not distressing to her. Using a combination of diet, exercise, medications, and behavioral therapy, Maggie had broken the vicious cycle in which gut problems made her anxious and the anxiety aggravated her gut (this is a good example of the brain-gut connection described in Chapter 2).
Effective treatment of people who have IBS must address both the physical symptoms of abdominal pain, bloating, diarrhea, and constipation and the emotional and mental aspects that often accompany this chronic disorder. The symptoms of IBS are ones that can be emotionally upsetting in themselves, and they can seriously disrupt daily life and work routines, causing additional distress. The tendency of the disorder to recur episodically and the frustrating process of trial and error to find an effective treatment that many patients go through can be sources of anxiety and stress. And, as Maggie’s case illustrates, the emotional stress of the disorder fuels the symptoms.
The following sections describe psychological, hypnotherapeutic, and psychiatric treatments that may improve symptoms for people who have IBS symptoms.
Many people who have chronic IBS symptoms that are considered moderate to severe have coexisting anxiety or depression or suffer from panic attacks or a somatization disorder. Somatization disorders are characterized by patients inappropriately focusing on minor symptoms, feeling that everything is going wrong in their body, and thinking that no part of their body is healthy. Anxiety disorders are the most prevalent psychiatric problem in the United States after substance abuse disorders. Generalized anxiety disorders occur in about 5 percent (about 1 in 20) of the U.S. adult population. Up to two-thirds of people who suffer from anxiety also suffer from depression.
For many people who have IBS, their physical symptoms become inextricably interwoven with their mood problems. Symptoms of IBS can create feelings of anxiety: How bad will the episode be? When will the attack occur? How long will it last? People become nervous about how they will deal with the attack, and their anxiety increases as they think about how the attack will affect their other activities. Then the IBS symptoms flare and the patient’s level of anxiety worsens. All of a sudden, a vicious cycle develops, in which IBS symptoms cause anxiety and heightened anxiety aggravates the GI symptoms. A similar pattern occurs in people with depression and IBS; they find that their IBS symptoms worsen when they are more depressed.
Medications designed to treat IBS symptoms do not directly treat the anxiety and depression suffered by many patients who have IBS, and the IBS symptoms may resist treatment unless the accompanying emotional problems are treated. Psychological management of IBS begins with the recognition that coexisting depression, anxiety, panic disorder, or somatization disorder may contribute to the frequency and severity of IBS symptoms.
The brain-gut connection (see Chapters 2 and 3) is always present in IBS, and we believe that visceral hypersensitivity contributes to the disorder, but not everyone who has IBS also has an anxiety disorder or depression or any other emotional problem. So, not every person who has IBS needs psychological or psychiatric therapy. Rather, psychological evaluation is recommended when it appears that anxiety, depression, or somatization is playing a role in the generation or expression of a person’s IBS symptoms. Psychological therapy may be very helpful for anyone who answers yes to any of the following questions: Are you frequently anxious? Have you ever been treated for anxiety? Are your gut problems aggravated by stress? Do they get worse when you are anxious? Do you frequently feel depressed? Are your IBS symptoms worse when you are depressed? Do you find that you think about and worry about your health a lot? Are you pretty sure there is something seriously wrong with you, even though your doctor says there isn’t? Another type of patient who can be helped by psychological therapy is one who is having trouble accepting the reality of having IBS or who is convinced that somewhere there is a single medicine that is going to make all the symptoms go away forever. Many people who have IBS benefit from a multidisciplinary approach to treating their IBS, involving cognitive behavioral therapy, stress management, and medications to treat both IBS symptoms and any emotional difficulties. These treatments are described below.
Using cognitive behavioral therapy, people who have chronic medical problems can be taught skills and methods for dealing with their symptoms in a positive, rather than a negative, manner. Cognitive behavioral therapy (CBT) aims to help people change behaviors and thought processes that produce and maintain emotional distress. It can improve physical symptoms and eliminate feelings of hopelessness or helplessness and inappropriate fears and actions. In addition, CBT teaches patients how to control many of the negative thoughts that automatically appear when a certain physical symptom develops. Cognitive behavioral therapy is based on two key assumptions: first, that some symptoms can be learned, and that these symptoms represent specific deficits in cognitive and behavioral functioning; and second, that individuals can be taught to modify behaviors and thought patterns that can precipitate or worsen these symptoms, therefore improving the symptoms with a proper course of therapy. For example, some patients who have intestinal urgency and diarrhea start to assume that any episode of diarrhea will lead to severe pain, extreme diarrhea, and fecal incontinence. This automatic, negative thinking dramatically and adversely influences their physical and emotional health. Cognitive behavioral therapy teaches these people effective ways to deal with their symptoms in a positive manner and skills and mechanisms to improve their symptoms. In the end, this means that a small flare of their IBS symptoms does not lead to a downward spiral in their overall health.
People receiving CBT generally attend regularly scheduled group or individual sessions. Each session is run by a behavioral psychologist. Psychologists are trained completely differently from psychiatrists; they are not medical doctors, they emphasize counseling and discussion, and they are not authorized to prescribe medications. Patients are asked to identify their symptoms, are provided with education about their condition, and are taught various strategies for dealing with their symptoms. The message of such a program is that symptoms can be identified and managed in a positive manner. Many CBT programs include techniques to promote relaxation and manage stress. Relaxation therapy teaches patients to incorporate calm into their daily activities, to induce a sense of mental and emotional relaxation whenever they need it. The focus is positive and forward thinking. One goal of CBT is to deal with things proactively, not reactively. Another goal is to reduce avoidance behavior (like the extremely limited diet of Jean, whose story is in Chapter 10). When used as part of treatment for a chronic medical problem, the message of CBT is that patients have the skills and abilities to understand and manage their symptoms on a daily basis. By teaching appropriate management strategies to people who have IBS, CBT can provide them with the tools to prevent small IBS flares from snowballing into major crises.
The use of hypnosis to treat chronic medical problems is relatively new. Most of us are familiar with the concept of hypnosis, but many people have an outdated and incorrect understanding of the practice. The old-fashioned view is of a “parlor trick” in which the hypnotist puts someone in a trance by having him or her focus on a swinging pocket watch and then “planting” suggestions into the person’s head. On awakening, the person who was hypnotized is made to perform the suggestion when a specific signal is provided. This process was acted out in countless movies and television shows. This stereotypical view of hypnosis is outdated and factually incorrect, as people who are hypnotized are not really put into a trance, nor can they be made to do something against their will.
Hypnosis is slowly gaining acceptance in the medical community as a reasonable and viable treatment option for a variety of chronic medical problems. It has been used successfully in clinical and research settings to treat high blood pressure, tobacco abuse, alcohol abuse, chronic pain, and other disease states. In these settings, hypnosis is performed by someone who has been specifically trained in the therapeutic use of this technique. Multiple sessions are usually required, typically 1 session a week for 8 to 12 weeks. During each session, the patient is placed into a hypnotic state. This usually takes place in a warm, quiet room without distractions. The patient is first asked to concentrate on an image while the hypnotist relaxes the patient with soothing words. The patient then closes her or his eyes, and the hypnotist verbally guides the patient through slowly relaxing all of the muscles. This process is called “induction.” As the session progresses, the hypnotist uses various techniques to place the patient into a deeper state of relaxation. Depending on the patient’s personality, susceptibility to hypnosis, and goals, the state of hypnosis will be deeper or lighter. When the patient is very calm and relaxed and not distracted by internal thoughts or external noises, the hypnotist will provide thoughts, suggestions, and guided imagery for the patient to use to improve his or her symptoms. Patients can then use these suggestions to help themselves. Some patients even learn to induce a state of hypnosis on their own.
The exact mechanism by which hypnosis works is not known. Research studies using PET (positron emission tomography) scans have demonstrated that hypnotized people undergo changes in the metabolic activity of certain parts of their brain that are concerned with pain. In 1996, after reviewing the data on hypnotherapy for cancer pain, the National Institutes of Health judged that hypnosis was an effective intervention for alleviating pain from cancer. Over a dozen studies have now been published on the efficacy of hypnotherapy in the management of IBS. However, these studies were all performed in Europe, most in the United Kingdom. The studies consistently showed that hypnosis leads to an improvement in many of the symptoms of IBS, although the results of some studies are limited by design flaws and small numbers of participants.
Recently, researcher Peter Whorwell and colleagues from Manchester, England, published a long-term follow-up study of 273 patients who had IBS and completed a course of gut-directed hypnotherapy. Seventy-one percent of those who responded reported that they had good initial responses to hypnotherapy, and 81 percent of these stated that they had long-term improvement in their IBS symptoms. Despite the fact that the exact mechanism by which hypnosis improves symptoms of IBS remains unknown, these results are quite exciting, and they support the idea that hypnosis should be considered a viable treatment alternative or complement for patients who have IBS. It is especially encouraging that patients receiving hypnotherapy used medications less frequently for their symptoms and sought out consultation with their doctor less often. Although the results of this large study are positive, they do warrant confirmation by a large, multicenter trial.
Theoretically, then, it is a good idea to treat patients who have chronic IBS symptoms with hypnotherapy. Here in the United States, however, this can be quite difficult. It can be difficult to find someone who is well trained in hypnosis. At present, an extremely limited supply of suitably trained and experienced practitioners live in the United States. In addition, it is important to find a hypnotherapist who is interested in using hypnosis to treat IBS, as opposed to helping someone stop smoking. Although the technique may be similar, the actual therapy is quite different for these two very different disorders.
Hypnosis works well for some people but not for all. Some people seem to be more susceptible to the influences of hypnosis than others, just as people differ in their responses to medications. Also, most insurance companies don’t pay for hypnosis sessions. In fact, many insurance companies actively discourage practitioners from referring patients for this type of therapy, since it usually requires an out-of-network referral.
Some people who have severe IBS have significant problems with anxiety and depression. Although most primary care physicians feel comfortable treating patients who have mild depression or anxiety, psychiatrists are usually better equipped to treat patients who have severe mental and emotional problems. Psychiatrists begin their training by going to medical school; they are then required to spend an additional year of training in internal medicine, to become familiar with medical disorders. They then spend an additional three to five years focusing on psychiatry. In contrast to psychologists, who are not medical doctors and cannot prescribe medications, psychiatrists are likely to incorporate medications into their treatment plan. Patients who have severe anxiety or depression may require multiple medications or medications that can be accompanied by uncommon side effects. Some may need a period of inpatient care.
People who have severe IBS symptoms and significant anxiety or depression are more likely to note an improvement in their IBS symptoms when they are treated by both their primary care physician or gastroenterologist and also a psychiatrist. An interactive team approach treats the whole person, although the psychiatrist focuses on the complicated mental and emotional issues while the internist or gastroenterologist concentrates on the physical symptoms. Consistently, when anxiety and depression are under control, the patient feels better able to address the symptoms of IBS. This dual treatment approach is more likely to lead to an improvement in both aspects of the person’s health.
• Patients who have severe or difficult-to-control IBS symptoms frequently also suffer from anxiety, depression, or a somatization disorder.
• Effective treatment for these patients must include therapy directed at the emotional and psychological components of this chronic disorder.
• Cognitive behavioral therapy, hypnotherapy, and therapy with a psychiatrist or psychologist are all worthwhile treatment options that may lead to an improvement in IBS symptoms and quality of life.