Association of Participation in a Mindfulness Programme With Bowel Symptoms, Gastrointestinal Symptom-Specific Anxiety and Quality of Life

D. J. Kearney; K. McDermott; M. Martinez; T. L. Simpson;

Disclosures

Aliment Pharmacol Ther. 2011;34(3):363-373. 

In This Article

Abstract and Introduction

Abstract

Background Stress perception and GI-specific anxiety play key roles in irritable bowel syndrome (IBS). Mindfulness-based stress reduction (MBSR) is a widely available stress reduction course, which has not been evaluated for IBS.
Aim To determine whether participation in MBSR is associated with improvement in bowel symptoms, GI-specific anxiety, and IBS-Quality of Life.
Methods This is a prospective study of 93 participants in MBSR. We applied measures of Rome III IBS status, bowel symptoms (IBS-Severity Scoring System, IBS-SSS), IBS-Quality of Life (IBS-QOL), GI-specific anxiety (Visceral Sensitivity Index, VSI), mindfulness (Five Facet Mindfulness Questionnaire-FFMQ), and functional status (SF-8) at baseline and 2 and 6 months after enrolment.
Results At 2 months, participation in MBSR was associated with small nonsignificant changes in IBS-SSS, IBS-QOL and VSI: d = −0.25, d = 0.08, d = −0.16, respectively. At 6 months, there was no significant change in IBS-SSS (d = −0.36); whereas for IBS-QOL and VSI there were significant improvements (IBS-QOL: d = 0.33, P = 0.044; VSI: d = −0.40, P = 0.014). For patients meeting Rome III IBS criteria (n = 43), changes in IBS-SSS, IBS-QOL and VSI were not statistically significant, but there was a significant correlation between the change in VSI and the change in FFMQ across the three time periods (r = 0.33).
Conclusions Participation in MBSR is associated with improvement IBS-related quality of life and GI-specific anxiety. Randomised controlled trials are warranted to further assess the role of MBSR for IBS symptomatology.

Introduction

Irritable bowel syndrome (IBS) is a common, symptom-based syndrome estimated to affect approximately 10–15% of the adult population of North America.[1] It has been estimated that IBS accounts for 12% of caseloads in primary care, and the total direct and indirect monetary costs of IBS are enormous.[2–5] IBS, as defined by the Rome criteria, is characterised by chronic abdominal pain or discomfort associated with a change in bowel habits.[6] The Rome criteria provide a standardised method of defining IBS for research purposes, but many patients who suffer from chronic gastrointestinal symptoms do not meet strict Rome criteria for IBS.[7,8] Symptoms of IBS are a source of significant distress for patients, which results in a reduction in quality of life across multiple domains of functioning when compared with the general US population.[9–14] Severe IBS has a health utility similar to stage III congestive heart failure and rheumatoid arthritis, and when health status for patients with IBS is compared with patients with diabetes mellitus or end-stage renal disease, IBS patients score lower on several domains of health.[15,16]

Recommended treatments for IBS are symptom-focused and include dietary, pharmacological and psychosocial interventions. Some patients with mild symptoms may respond to education, dietary and lifestyle modifications, whereas patients with moderate or severe symptoms are usually treated with pharmacological or psychological interventions.[8,17] For patients with constipation-predominant symptoms, a trial of increased dietary fibre or a stool softening regimen is often recommended, whereas for patients with diarrhoea-predominant symptoms, loperamide or other agents that slow intestinal motility are often prescribed. For patients with abdominal pain as a prominent symptom, antispasmodics or low-dose antidepressants are typically recommended.[8,17] Psychological treatments, such as cognitive behavioural therapy (CBT) or hypnotherapy, are sometimes recommended when symptoms are refractory to treatment. The effectiveness of cognitive behavioural therapy for IBS is diminished when there are high levels of baseline depression or anxiety.[18–20] Overall, the treatment options for IBS are generally unsatisfactory; approximately one-third of patients do not achieve adequate response with existing treatments.[8] The lack of patient satisfaction with existing approaches is reflected by findings that 16–33% of IBS out-patients seek alternative medicine consultation for their symptoms.[21–24] Given the potential for poor health status relative to other chronic illness and the significant increases in health care utilisation attributable to IBS, we are in need of additional treatment modalities for IBS.[2–5,9–14]

There is evidence that the impairment in quality of life in IBS is not primarily caused by the severity or type of bowel symptoms a person experiences. Rather, reduced quality of life in IBS is largely related to extraintestinal factors, including symptoms of chronic stress (e.g. tiring easily, feeling nervous, feeling hopeless, difficulty sleeping), the belief that there is something seriously wrong with the body, and interference with sexual function.[25] Patient-reported IBS illness severity, a construct related to but distinct from quality of life, has also been shown to be significantly related to the belief that the GI symptoms represent a serious underlying problem with the body.[26] Persons with IBS demonstrate increased anxiety regarding gastrointestinal sensations (termed GI-specific anxiety); this has been shown to play a role in disease severity and is a key determinant of whether a person meets diagnostic criteria for IBS.[27] GI-specific anxiety includes the thoughts, emotions and behaviours that stem from fear of GI sensations, symptoms, and the context in which these occur. GI-specific anxiety has been hypothesised to function as an endogenous stressor, which leads to exaggerated autonomic and neuroendocrine responses, changes in intestinal function and visceral pain perception and GI symptoms.[27,28] A situation that might produce GI-specific anxiety is being someplace where the location of bathroom facilities is not known, such as restaurants or social gatherings. Cognitions accompanying GI symptoms might include beliefs of poor ability to control symptoms, or beliefs that the GI sensations experienced represent a serious underlying illness. These contexts and cognitions can lead to fear, worry and avoidance behaviours, which can be associated with reduced quality of life. Persons with IBS also have heightened stress perception, which adversely affects symptoms[29–32] and hypervigilance towards bodily sensations and symptoms.[33,34] The key roles of stress, GI-specific anxiety, hypervigilance towards bodily sensations, and extraintestinal factors in quality of life suggest that providers would improve treatment outcomes by teaching methods to reduce anxiety and stress, rather than solely focusing on managing specific bowel complaints (such as the frequency or consistency of bowel movements).[25]

Prior research on stress reduction techniques for IBS shows that improvement in IBS symptoms correlates with improvement in psychological symptoms in most trials.[1] However, prior studies of stress reduction for IBS (most of which were performed approximately two decades ago) combined multiple behavioural therapies (e.g. relaxation therapy, stress management and biofeedback) as part of a multicomponent package, making it difficult to interpret the factor(s) responsible for any improvement in outcomes.[35–42] One validated and increasingly utilised method to reduce stress is through teaching mindfulness. Mindfulness emphasises attentiveness to present moment experience, and has been defined as 'the awareness that emerges by way of paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment'.[43] In mindfulness practice, thoughts, bodily sensations and emotions are regarded as objects of attention. In the context of IBS, enhanced mindfulness would be hypothesised to decrease GI-specific anxiety by teaching techniques that foster reappraisal of fears, thoughts, and beliefs related to GI sensations.

A validated clinical method of teaching mindfulness is an 8-week class series called mindfulness-based stress reduction (MBSR),[44] which is widely available throughout the US and internationally. Prior studies indicate that mindfulness skills are increased through participation in MBSR and other similar training programmes.[45] At a minimum, most mindfulness training programmes include instruction, scheduled home practice, as well as informal mindfulness practices.[45,46] Recent studies by a group in Sweden have evaluated a mindfulness-based programme, which also included exposure therapy, tailored to individuals with IBS and found that it was associated with clinically significant improvement in IBS symptoms and quality of life.[47,48] Changes in mindfulness were, however, not assessed. We sought to examine the association of a widely available 8-week MBSR programme with measures of bowel-related symptoms, GI-specific anxiety and quality of life. Given the high prevalence of post-traumatic stress disorder (PTSD) in our Veteran patient population, we also sought to explore whether outcomes differed according to whether a person had symptoms compatible with PTSD, which has clinical hallmarks of hypervigilance and avoidance, and might be expected to influence the impact of the intervention. We hypothesised that participation in MBSR would be associated with improvement in measures of bowel symptoms, IBS-related quality of life, gastrointestinal symptom-specific anxiety and health status.

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